Update Expected for VA/DoD Later This Year
By Annette M. Boyle
BETHESDA, MD — The leading guidelines for diagnosis and management of chronic obstructive pulmonary disease (COPD) include significant new recommendations this year that promise to alter the way the disease is staged and treated worldwide.
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) released a new strategy for diagnosis, management and prevention of COPD in late January. After years of minor tweaks, the latest document breaks new ground with recommendations that move away from relying primarily on spirometry for staging of the disease and lay the groundwork for more aggressive use of inhalers and other therapies.1
GOLD was launched in 1997 as a collaborative effort between the U.S. National Institutes of Health, the U.K.’s National Heart, Lung and Blood Institute and the World Health Organization and now sets the standards that “the other guidelines all follow,” said Maj. Michael Perkins, MD, director, respiratory therapy, and staff physician in pulmonary and critical care medicine at Walter Reed National Military Medical Center in Bethesda, MD. “And this year, there were some significant changes.”
One of the biggest changes came in the recommendations for patient assessment. Prior guidelines, including the VA/DoD Clinical Practice Guideline for Management of Outpatient Chronic Obstructive Pulmonary Disease, which was last updated in 2007, determined the severity of the disease based largely on the results of spirometry.
New VA/DoD guidelines should be completed in November of this year, according to the effort’s coordinator, retired Col. Ernest Degenhardt, chief, evidence-based practice, quality management division, U.S. Army Medical Command, Joint Base San Antonio, Fort Sam Houston.
Obtaining a more holistic view of the patient’s condition affects the subsequent course of treatment and may provide greater relief for the Army’s nearly 80,000 COPD patients and the VA’s 969,000.
COPD is about four times more common in veterans than in the general population, according to David Au, MD, investigator in the VA’s Northwest Center of Excellence for health services research and development and associate professor of medicine and pharmacy at the University of Washington. Smoking, which accounts for 80% to 90% of the risk of developing COPD, is 40% more common among veterans and 50% more common among deployed servicemembers than their never-deployed counterparts.2
Symptoms and Exacerbations
“Spirometry alone is a poor predictor of disease progression. Two people with very similar findings of spirometry and similar stages can have much different levels of symptoms and rates of decline of lung functions,” Perkins noted. The new guidelines “specifically recommend assessing the level of symptoms a patient has and the frequency of exacerbations, and then incorporating the findings of spirometry.”
“Looking at the symptoms and exacerbations is important because some inhalers work better for symptom control and quality of life than others,” he said..Based on prior guidelines, a patient with spirometric results that indicated moderate pulmonary impairment but experienced more troublesome symptoms might not have been offered medications that would have managed those symptoms better, Perkins added.
The current recommendations come on the heels of a decade of research on COPD symptoms, treatments and mortality. The GOLD guidelines “are based on a wealth of randomized clinical trials that we now have for COPD, particularly related to exacerbations. As a result, we have evidence-based recommendations for treatment, which had been a deficiency 10 years ago,” Au said.
Patients who have more frequent exacerbations tend to experience a more rapid and more severe decline in lung function and greater mortality rates. Including more data in the treatment algorithm, Perkins said, “really changes the use of inhalers. The new assessment lets us use them more aggressively than previous guidelines, with an overall goal of improving symptoms and reducing exacerbations.”
Management of COPD extends beyond selecting the right inhaler, Perkins pointed out. The first priority is getting patients to stop smoking, which decreases the loss of lung function and decreases mortality. A patient with COPD should expect to discuss smoking cessation in every visit with a medical professional.
“If smoking cessation is brought up every time, that’s been shown to correspond to higher rates of quitting smoking,” Perkins explained. Walter Reed and many military clinics offer comprehensive smoking cessation services that incorporate counseling, pharmacotherapy and other support.
Even after diagnosis with COPD, about 20%-25% of patients continue to smoke, Au noted. “While most give it up, the high rate of continued smoking speaks volumes about how addictive tobacco really is.”
Recent research identified a novel factor in preventing or encouraging servicemembers to quit smoking while on active duty. In a study published in the Annals of Behavioral Medicine, Christopher Harte, MD, of the VA Boston Healthcare System and colleagues found that both deployed and nondeployed soldiers who experience high levels of social bond, loyalty and trust toward fellow soldiers and leaders have lower levels of initiating and higher rates of cessation than those in less cohesive military units.3
1. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive pulmonary Disease. January 2014.
2. Institute of Medicine: Combating tobacco use in military and Veteran Populations. Washington DC: the National Academies Press, 2009.
3. Harte CB, Proctor SP, Vasterling JJ. Prospective Examination of Cigarette Smoking Among Iraq-Deployed and Nondeployed Soldiers: Prevalence and Predictive Characteristics. Ann Behav Med. 2014 Jan 29. [Epub ahead of print]
With a long history of point of care testing at both of its predecessor organizations, the Walter Reed National Military Medical Center (WRNMMC) laboratory services staff were keenly aware of the advantages of using portable testing devices to obtain rapid patient assessments.
Since the launch of the Opioid Safety Initiative in 2012, the VA has implemented a number of steps designed to reduce the use of opioids and the risk of addiction and overdose among veterans.