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Funding for this newsletter series was provided by  |
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| Pulmonary Practice Pearls for Primary Care Physicians 9-part eNewsletter series |
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Vol 1, Issue 1 |
| Primary care physicians routinely see patients with chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease (COPD). Although treatment guidelines are available, we still need practical information that translates guidelines and other evidence into diagnosing and managing these diseases. Each issue in the Pulmonary Practice Pearls for Primary Care Physicians eNewsletter series will focus on a key topic in the management of COPD or asthma within the context of current national guidelines and clinical practice. Topics will be brought to life through the presentation of clinical cases, and an emphasis will be placed on applying key learnings to clinical practice. |
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Recognizing and Managing COPD in Patients With Multiple Morbidities In 2007, the United States had the second highest death rate for COPD among 16 industrialized nations.1 Most cases of COPD are caused by cigarette smoking2 and are associated with chronic, often progressively worsening, airflow limitation resulting from reversible and irreversible changes in central and peripheral airways.3 Together with other less common chronic lower respiratory diseases, COPD is the fourth leading cause of death in the United States, behind heart disease, cancer, and stroke.1 In 2007, approximately 12 million men and women in the United States were diagnosed with COPD, and a similar number of people may have undiagnosed COPD.1 The number of women self-reporting symptoms of COPD increased in the second half of the 20th century,4 potentially because smoking habits between men and women are now similiar.5 Since the early 1980s, the prevalence of COPD in women has been higher compared with men.1,4 Although COPD-related mortality rates in men decreased slowly in the 1990s, then sharply decreased in 1999, rates in women increased in the 1990s, and plateaued in 2006.1 COPD and Multiple Morbidities A complication both for the diagnosis and management of COPD is that most individuals with COPD have multiple other morbidities.6 Consider the case below:
In many regards, Mary is a typical patient with COPD; she’s in her late 50s, with undiagnosed COPD and multiple additional morbidities—in her case osteoporosis, hypercholesterolemia, and possibly depression. (See Case.) Patients with COPD have a higher frequency of morbidities than age-, sex-, and geographically matched control samples.7 In particular, COPD patients are at increased risk for pneumonia,8 osteoporosis,8 respiratory infections,8 lung cancer,9 and heart disease.9,10 Results of a US national telephone survey of 1003 patients with COPD showed that nearly 50% of patients with COPD had 6 to10 additional morbidities, approximately 25% had 11 to 15 morbidities, and about 7% had 16 to 25 morbidities.11 There also was a preponderance of cardiovascular diseases among both sexes and a 39% prevalence of osteoporosis among surveyed women.11 Similarly, a retrospective analysis of data from more than 20,000 participants of 2 cohort studies conducted by the National Institutes of Health demonstrated a significant association between COPD and the presence of cardiovascular disease, hypertension, and diabetes.6 Importantly, results of a large case-control study of approximately 90,000 US patients followed for an average of 3 years showed that the presence of COPD was associated with significantly increased risks of hospitalization and mortality from cardiovascular diseases, including a 5-fold increased risk of death from congestive heart failure.12 Coincidental—or Not? What's Behind the Other Morbidities Some concurrent morbidities in patients with COPD may be coincidental, whereas others may relate to underlying pathophysiology or complications of the disease.3 Depression and anxiety may be unrelated to COPD’s underlying pathogenesis3 but affect about 40% of patients with COPD and contribute to increased functional disability.13 In contrast, lung cancer and ischemic heart disease may share a common etiology with COPD: smoking.3,14 Systemic inflammation has been suspected as a pathogenic link between COPD and extrapulmonary morbidities such as cachexia, osteoporosis, cardiovascular disease, and perhaps depression (FIGURE 2).14,15 An interaction between COPD and heart disease is also suggested by a recent post hoc analysis of data from the European Respiratory Society study on Chronic Obstructive Pulmonary Disease (EUROSCOP).16 Three years of therapy with inhaled budesonide, an inhaled corticosteroid, was associated with a significant reduction in the incidence of ischemic cardiac events, including angina pectoris and myocardial infarction, among smokers with mild COPD not currently receiving treatment with a beta-blocker.16 Why Does COPD Go Undiagnosed in So Many Patients? Many concurrent morbidities in patients with COPD (eg, hypertension) are more easily diagnosed than early-stage COPD, or are so serious (eg, heart disease) that they dominate a patient’s symptom profile and may absorb a physician’s attention at the expense of seemingly less serious symptoms. This dynamic may explain the findings of a Spanish population study that showed that at least 60% of patients with cardiovascular disease and spirometrically confirmed airflow limitations received no respiratory treatment.17 Another impediment to the timely diagnosis of COPD is that the clinical manifestations of COPD are highly variable.18 Furthermore, some COPD symptoms (eg, dyspnea) are similar to those of asthma2 and overlap with those of left ventricular heart failure.19 An evaluation of lung function by prebronchodilator and postbronchodilator spirometry is most important for the diagnosis of COPD in any patient with persistent respiratory problems (TABLE 1). Smokers with concomitant cardiovascular disease should also have spirometry testing, unless contraindicated due to unstable angina or recent myocardial infarction.20 However, a definitive diagnosis of COPD often requires additional tests (eg, electrocardiogram, B-natriuretic peptide, eosinophils) to distinguish between COPD, asthma, and heart failure.2,19 Comanagement of COPD and Concurrent Morbidities: Medication Challenges Comanagement of COPD and concurrent morbidities poses significant challenges for the treating physician. The possibility of drug−disease state interactions may preclude preferred therapeutic options for the treatment of patients with multiple morbidities. An example of possible treatment conflicts is the comanagement of COPD and osteoporosis. The reasons for the association of COPD and increased risk of osteoporosis are multifactorial and poorly understood. Although recognized risk factors such as smoking and older age increase the risk of osteoporosis in COPD patients, it has been suggested that COPD-related systemic inflammation and corticosteroid use may further increase this risk.21,22 A large observational study conducted in Italy identified inhaled and oral corticosteroid use as significant independent risk factors that doubled the risk of osteoporosis, with a 3-fold increase in risk for combined oral and inhaled therapy.22 In contrast, 3-year data from the EUROSCOP study showed no effect of inhaled corticosteroid use on vertebral fracture.23 Although the 2 studies investigated different end points, their results exemplify the complexity associated with comanaging COPD that requires chronic inhaled corticosteroids and recurrent bursts of oral corticosteroids in women with osteoporosis. Another possible treatment conflict exists with beta-blockers and bronchodilators. Although beta-blockers are recommended after an acute myocardial infarction, use may compromise the pulmonary effects of β2-adrenergic agonists used as bronchodilators in COPD.24 Fortunately, advances in the availability of β1-selective blockers (ie, cardioselective)25 and recent studies showing benefits with these agents in COPD patients who underwent major vascular surgery26 or recently experienced a myocardial infarction have nearly obviated this concern.27 These findings allow for appropriate comanagement of COPD with long-acting β2-adrenergic agonists and cardiovascular disease with β1-selective blockers. Guidelines seldom provide recommendations for the comanagement of COPD and multiple other morbidities. Thus, family physicians and other primary care physicians have to manage these diseases based on each patient’s clinical history and coordinate specialty care when needed to ensure optimal management of their patients. Management Guidelines Comprehensive guidelines for the diagnosis and management of COPD have been provided by the GOLD guidelines. Based on spirometric characteristics, GOLD distinguishes between 4 stages of COPD (FIGURE 1)3 and has established the following goals of disease management3:
To achieve these goals, the GOLD guidelines recommend active reduction of risk factors, including smoking cessation and influenza vaccination, for patients at all 4 stages.3 The Centers for Disease Control’s Advisory Committee on Immunization Practices recommends pneumococcal (polysaccharide) vaccination and tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination for adults,28 but the role of these vaccines in COPD management remains unclear. Based on a limited body of evidence from randomized controlled trials, the GOLD guidelines recommend the pneumococcal vaccine for COPD patients 65 years and older and for COPD patients younger than age 65 with an FEV1 <40% predicted.3 Short-acting bronchodilators should be prescribed for as-needed use. Daily therapy with long-acting bronchodilators is recommended for moderate to very severe COPD, and an inhaled corticosteroid should be added for patients with severe or very severe COPD and repeated exacerbations. Two landmark trials in COPD, the TOwards a Revolution in COPD Health (TORCH) and the Understanding Potential Long-Term Impacts on Function with Tiotropium (UPLIFT) studies, permitted inclusion of patients with a coexisting nonrespiratory disease that was not unstable or severe enough to interfere with study participation.29-31 Recent results of the TORCH study showed that the combination of a long-acting β2-adrenergic agonist (salmeterol) and an inhaled corticosteroid (fluticasone) for patients with moderate to severe COPD reduced the annual rate of acute exacerbations and improved health status and lung function.32 Importantly, adverse event data indicated no increased probability of bone fractures with combination therapy.32 Results of the 4-year UPLIFT trial showed that treatment with tiotropium (an inhaled anticholinergic) significantly reduced not only the risk of exacerbations and delayed first hospitalizations but also reduced the risk of serious events of angina, respiratory failure, congestive heart failure, and myocardial infarction.30 Based on this information, then, what is the appropriate therapy for Mary?
Treating patients like Mary who have COPD and multiple other morbidities is a common occurrence in primary care. Maximizing the care you provide to these patients hinges on making an early diagnosis, taking steps to reduce risk, and considering the consequences for concurrent morbidities when developing a COPD treatment plan. References
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