An expert panel discusses appropriate transitions and adjustments to COPD treatment approaches.
Jeffrey D. Dunn, PharmD, MBA: We’ve talked about this a little, but I want to ask this specific question. How do we assess what’s working, what isn’t working, and when we’re going to step up or change therapies? What are some real-world measures that you’re using in practice?
Courtney Crim, MD: One thing that’s critically important is that the patient has to appreciate and recognize that they’re benefiting from any type of therapy you give them. That’s why I like the point that you raised related to asthma in terms of hitting a person hard. Rey mentioned starting with dual bronchodilators as opposed to monotherapy. If a patient comes to see you because their disease is impacting them, and you put them on some therapy for 3 months, that’s your intent. But if they aren’t seeing any benefit, then one thing that could happen is they question whether you’re giving them anything that works.
In general, my goal is to hit them hard and then de-escalate if necessary in that process. I do what I can to control whatever their main issue is, such as having to go to the hospital or the ED [emergency department] for frequent worsening of their symptoms—ie, exacerbations, or the fact that they’re still having difficulty climbing the stairs or walking the mall with their significant other or their spouse. Those are the types of things I take into consideration.
One can definitely use tools such as the CAT [COPD Assessment Test] to give a sense of whether the person is getting better or worse. But the patient can often tell you whether they’re getting better or worse, and whether the therapies that you prescribe to have an impact on their shortness of breath are having an impact. Those are the things I take into consideration. The patient tells me whether the medication is having an impact, and then I occasionally use tools, such as the CAT, to gauge whether I’m having an impact with my therapy. If I started them on a dual bronchodilator based on how they initially presented to me, then I’ll step up to triplet therapy if I’m not meeting their goals. Those sorts of things. Patient feedback is very important because the patient needs to be heard, but there are objective patient-reported outcome tools that one can use as well.
Jeffrey D. Dunn, PharmD, MBA: That’s also important to understand, taking a step even further back. We all know what exacerbations are. But if somebody isn’t having exacerbations, they can still develop chronic progressive implications or issues. Correct?
Courtney Crim, MD: Correct. Therefore, it’s important to address that.
Jeffrey D. Dunn, PharmD, MBA: You answered one question I was going ask, about whether it’s feasible to step people back and de-escalate. You addressed that. I don’t know if anybody has comments about that. Is it standard practice, when somebody is having exacerbation, to hit them? If they’re doing well, then maybe we can step them back from triplet [therapy].
Reynold Panettieri, Jr, MD: My view is that less is more. Less medicine is better. The question is, when do you taper? When do you decrease? If we’re using an inhaled corticosteroid [ICS] to prevent exacerbations, but the patient hasn’t had exacerbations for years, maybe it’s time to step back the ICS. I’d rarely step back a LAMA [long-acting muscarinic antagonist]–LABA [long-acting beta-agonist] because I’ve already started that as my platform of therapy to maximize exercise tolerance.
I want to make 1 other point that Courtney made beautifully. Patient-reported outcomes are incredibly important. It’s interesting. When you have phase 3 drug studies, usually they’re based on FEV1 [forced expiratory volume in 1 second] and exacerbations; patient-reported outcomes are the third wheel. Often, they don’t hit patient-reported outcomes. It might be a little fuzzy because the modified MRC [Medical Research Council] tool or CAT test doesn’t have the same robustness as n FEV1 or an exacerbation rate.
In practice, what’s so interesting is patient-reported outcomes, No. 1. When I start a medicine and a patient doesn’t feel better, this is like taking a boulder and shoving it up a hill to try to get the patient to take the medicine. Because they come back and say, “Doctor, I don’t feel any better.” That’s the death wish for adherence. Courtney and Mike know that if a patient feels good, they’re likely to take the medicine. If they don’t feel good, they’re likely to look for another doctor. The bottom line is [to use] very practical approaches. Don’t dismiss patient-reported outcomes. Because if they don’t feel better, it’s a hard sell.
Transcript edited for clarity.