Treatment Options for Stable Chronic Obstructive Pulmonary Disease: Current Recommendations and Unmet Needs

Unmet needs

COPD remains underdiagnosed in the United States, with only 50% of individuals with impaired lung function reported to receive a formal diagnosis of COPD.^61,62 Opportunities for diagnosing COPD earlier in its course are being missed; 85% of patients consult primary care for lower respiratory symptoms in the 5 years before diagnosis of COPD, and might have been candidates for further evaluation of those symptoms, including spirometry testing.⁶³ Initiating treatment at early stages of COPD has the potential to improve patients’ health-related quality of life, and may provide opportunities to slow disease progression through interventions such as smoking cessation.⁶⁴ Practical approaches to improving early diagnosis in primary care involve the use of questionnaires and clinical suspicion to identify those appropriate for spirometry, the most reliable method for identifying patients with COPD.^3,9,65 Such methodology is currently under investigation, with early studies demonstrating the potential benefit of the COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE) questionnaire in conjunction with peak expiratory flow to gauge whether a patient requires further diagnostic evaluation.⁶⁶

In addition, the GOLD strategy and COPD Foundation guidelines emphasize that correct assessment of symptoms is of paramount importance in determining the most appropriate therapy (both pharmacologic and nonpharmacologic) for patients with COPD, but traditionally has not been used to inform management choices. Both guidelines therefore highlight the importance of symptom assessment ahead of therapeutic decision-making.

Poor adherence to prescribed therapies and inad­equate patient monitoring also need addressing. Two studies analyzing refill adherence data in patients with COPD and asthma in Sweden reported that only 28%–29% of prescribed treatments were dispensed with refill adherence that covered more than 80% of prescribed treatment time^67,68; a study in 5504 patients in the United States with a prescription of fluticasone propionate/salmeterol combination therapy found that more than half of patients only refilled their prescription once over the course of the 1-year study.⁶⁹ With studies showing incorrect use of inhalers in more than 50% of patients with COPD, incorrect inhaler technique is a significant contributor to poor treatment adherence.^70,71 Inhaler technique should be reviewed regularly with direct observation of patients’ technique. Assessment of the patients’ ability to use their current prescribed inhaler(s) is recommended before considering a change in treatment.⁷⁰ Errors in inhaler use are also associated with an increased rate of severe COPD exacerbations, increased risk of hospitalization, and poor disease control.^71,72 Important factors affecting inhaler use include age, education, product design, costs (copays and deductibles) for medications, and instruction and inhaler technique education from the health care providers.^70,72,73 Recent data support improvements in product design, training by the health care provider, and “self-training” by the patient (assisted by instructional video or other digital media) to increase adherence and reduce the frequency of handling errors.^10,70,74 Electronic monitoring devices, messaging systems, and cell phone applications are also being considered as ways to increase adherence.⁷⁵

Maintenance medication is an essential component of COPD management. However, patients with COPD often report that their preference is for medication that they can “feel” working, which may be implicated in their motivation to adhere to therapy.⁷⁶ Conversely, while maintenance medication may reduce exacerbations, and lessen a patient’s decline in lung function,⁷⁷ it may not have a significant impact on how they “feel.” As a result, patients may not take it as prescribed, contributing to poor adherence. It is therefore important for primary care physicians to acknowledge that the impact of taking the maintenance medication may not be felt immediately, and articulate the importance of maintenance therapy to their patients, as failure to adhere to treatment can have significant implications for longer-term outcomes such as symptom burden, quality of life, and exacerbation risk.¹¹

Regular patient follow-up is necessary to reinforce such information: patients with milder or stable COPD may be followed at 6-month intervals, while patients with severe or frequent exacerbations, or patients who have recently been hospitalized, require follow-up at 2- to 4-week intervals.⁷⁸

Conclusions

Defining personal treatment goals for patients with COPD can enhance patient and physician communication and encourage continued collaboration to improve adherence and outcomes. Regularly monitoring symptoms, exacerbations, and comorbidities via patient-focused questionnaires, and closely examining patient adherence and technique, form a fundamental part of care for patients with COPD. Recent updates to the GOLD and the COPD Foundation guidelines have emphasized the importance of symptom assessment in initiating COPD therapy, and continued assessment to appropriately escalate treatment. Nonpharmacologic therapies such as smoking cessation and pulmonary rehabilitation are recommended at all stages of COPD alongside pharmacologic treatment.