The American College of Chest Physicians and the Canadian Thoracic Society have issued new recommendations for reducing the risk of acute exacerbations of COPD.
The guideline, representing the first partnership of its kind between two of the largest thoracic societies in the world, includes 33 recommendations based on “an up-to-date, rigorous, evidence-based analysis of current randomized controlled trial data,” according to Dr. Gerard J. Criner, professor of pulmonary and critical care medicine, Temple University, Philadelphia, and his associates on the guideline’s expert panel.
“Exacerbations are to COPD what myocardial infarctions are to coronary artery disease: They are acute, trajectory changing, and often deadly manifestations of a chronic disease. Exacerbations cause frequent hospital admissions, relapses, and readmissions; contribute to death during hospitalization or shortly thereafter; reduce quality of life dramatically; consume financial resources; and hasten a progressive decline in pulmonary function, a cardinal feature of COPD,” Dr. Criner and his associates wrote (CHEST 2015;147:894-942).
Current COPD treatment guidelines state that prevention of exacerbations is possible, but they provide little guidance to clinicians regarding available therapies. The ACCP and CTS jointly commissioned their guideline to address “this important void in COPD management.”
Among their recommendations are the following:
• Patients with moderate, severe, or very severe COPD who had an exacerbation within the preceding 4 weeks should undergo pulmonary rehabilitation to prevent further exacerbations. In contrast, the data do not support pulmonary rehabilitation for those whose most recent exacerbation was more than 4 weeks earlier.
• Smoking cessation counseling and treatment are suggested as a component of a comprehensive clinical strategy to prevent COPD exacerbations. Quitting smoking is the only evidence-based intervention that actually improves COPD prognosis, because it mitigates further declines in lung function and reduces symptoms.
• Education plus case management together, to include direct contact with a health care specialist at least monthly, are recommended to prevent acute exacerbations; either measure alone is insufficient to reduce exacerbations.
• Administration of the 23-valent pneumococcal vaccine is suggested even though evidence does not specifically support the vaccine for preventing acute exacerbations. Rather, the vaccine benefits the general health of people aged 65 and older and of all adults who have underlying chronic medical conditions such as COPD.
• Annual administration of the influenza vaccine is recommended because of its benefit regarding general health and the fact that existing guidelines recommend it for COPD patients.
The guideline also addresses the use of numerous medications, alone or in combination, in great detail, including short- and long-acting beta-2 agonists, short- and long-acting muscarinic antagonists, inhaled corticosteroids, inhaled long-acting anticholinergics, long-term macrolides, oral and IV systemic corticosteroids, roflumilast (when chronic bronchitis is present), oral slow-release theophylline, oral N-acetylcysteine, oral carbocysteine, and statins.
There is a section on novel therapies, including agents that target airway inflammation such as adenosine A2A-receptor agonists, inhibitors of proinflammatory pathways, and activators of anti-inflammatory pathways. Other new approaches include drugs with antioxidant effects, drugs that facilitate lung regeneration, and mucoactive agents.