COPD Stakeholder Summit: Utilizing Peak Inspiratory Flow Rates to Individualize Treatment and Improve Outcomes - Episode 8

COPD: Individualizing Therapy

Initial strategies to treat chronic obstructive pulmonary disease that can be tailored based on patient appropriateness.

Neil Minkoff, MD: Dr Drummond, we talked about GOLD [Global Initiative for Chronic Obstructive Lung Disease] recommendations around treatment guidelines, and we know there are lots of treatment options. Tell me more concretely about your steps when a patient comes to you for COPD [chronic obstructive pulmonary disease] management. How do you start? What pharmacologic molecule and device combination are they likely to end up on?

M. Bradley Drummond, MD, MHS: The important and challenging thing is deciding how to take the treatment strategies published by GOLD and put those into action. The first step I take is confirming that they actually have COPD. That sounds like a silly statement, but it’s important for spirometry testing to confirm that the symptoms they’re having are caused by their airflow limitation. That’s the first step.

The second step, as I outlined earlier in our discussion, is to get a good assessment of their symptom burden and their future exacerbation risk. Because once you have those 2 key domains assessed, you can begin to stratify these patients into different categories, as Dr Mahler outlined. An exacerbation risk is defined by what you’ve done in a prior year. If you’ve had 2 or more outpatient exacerbations or 1 hospitalized exacerbation in the prior year, you’re considered at high risk for future exacerbations. If you have low symptom burden and low exacerbation risk, the GOLD treatment strategy suggests that you simply need a short-acting bronchodilator.

If you have a lot of symptoms, but you’re a low exacerbation risk, then you have the option of using either a singular, mono bronchodilator or a dual bronchodilator. There are good data that indicate combined dual bronchodilators increase FEV1 [forced expiratory volume in the first second of expiration], or lung function measurements, and reduce symptoms compared to monotherapy. They also likely reduce exacerbations compared to monotherapy.

Since I am in a tertiary care center, our patients typically have a few more symptoms, and we generally move toward a dual bronchodilator therapy for those symptomatic patients without a lot of exacerbation risk.

If individuals have high exacerbation risk and high symptom burden, then you have the option of dual bronchodilator therapy, or you can begin considering inhaled corticosteroid-containing regimens with bronchodilators.

There’s a lot of discussion in the COPD world about when we should incorporate inhaled corticosteroids into a patient’s regimen. Certainly, the patients who we probably should not be using it in are those who have a lot of pneumonia events, which would be one of the potential [adverse] effects. They have consistently low blood eosinophils, which seems to be a predictor of who may not respond to inhaled steroids. Patients with other chronic lung infections shouldn’t be using them either.

Conversely, the individuals in my clinic for whom I would tend to use inhaled corticosteroids earlier include: patients who have been hospitalized for an exacerbation, because as I discussed earlier, it’s really a life-threatening event in the future; patients who have blood eosinophils that are elevated—the GOLD treatment strategy recommends a threshold of 300 [cells/μL] or more; or patients with a history or concomitant asthma. Those patients can help tease out who may benefit from the inhaled steroids. But at the end of the day, assess symptoms, assess exacerbation risk, place them in a low- or high-risk category based on those 2 domains, and then you can select your molecules appropriately from there.

This activity is supported by an educational grant from Boehringer Ingelheim.