SEATTLE — In pursuit of the twin goals of COPD treatment — maintaining maximum lung function and improving quality of life — military and VA clinicians customize a mix of therapies that range from recently approved medications to time-tested exercise.
The new GOLD guidelines note that appropriate pharmacologic therapy can reduce COPD symptoms and reduce the frequency and severity of exacerbations. In addition, pharmacotherapy can support smoking cessation and improve exercise tolerance in patients with COPD. So far, however, only smoking cessation and oxygen therapy for patients with severe hypoxemia have been clearly shown to cut mortality rates.
“Recent studies of new pharmaceutical agents have not definitively shown a reduction in mortality, though some appear to show a reduced rate of lung loss,” said 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.
Traditionally, inhaler therapies for COPD have been based on three types of bronchodilators: beta2-agonists, anticholinergics or methylxanthines. These are sometimes combined with inhaled corticosteroids for patients with moderate to severe COPD, although long-term treatment with systemic corticosteroids is not recommended.
In recent years, the combinations of the long-acting formulations of these drugs have been embraced because they seem to improve efficacy and decrease the risk of side effects compared with increasing the dosage of any single bronchodilator. They are, however, associated with increased risk of pneumonia. Prophylactically, military and VA providers strongly advocate pneumococcal and influenza immunizations for patients with COPD.
In 2013, the Food and Drug Administration approved several new drugs for COPD. Among them were three inhaled powders: an anticholergenic, aclidinium bromide, and combinations of fluticasone furoate and vilanterol, and umeclidinium and vilanterol. Olodaterol, a new long-acting beta agonist, is pending FDA approval.
The four new FDA-approved drugs are available through the non-formulary request process at the VA. Aclidinium bromide, fluticasone fuoate/vilanterol and roflumilast are on the TRICARE formulary.
“Up to now, we’ve had three types of bronchodilators. The guidelines included a fourth type, roflumilast, and it works in a different way than classic inhalers to reduce exacerbations. It inhibits phosphodiesterase type 4 (PDE4) and has anti-inflammatory effects and may have bronchial dilator function as well,” noted 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.
“It’s the first new tool in our armamentarium to reduce exacerbations for those not responding sufficiently on standard therapy,” he noted. The new PDE4 inhibitors, a pill rather than inhaled medication, target phenotypes with chronic bronchitis and high exacerbation rates.
The traditional medications used to manage COPD may be underutilized, however. “The long-acting beta agonists and steroids reduce exacerbation rates in the range of 20-30%,” Au said. “They are equivalent to beta blockers or ACE inhibitors in treating heart conditions. With such a large effect, we should be using them more, but many providers have a level of nihilism about treating COPD that is a tough nut to crack. There’s an issue with the lack of recognition of the effect these drugs have on exacerbations and the large impact they have on quality of life.”
New devices also are on the horizon that might aid COPD management, according to Perkins.
“While they haven’t been proven to be beneficial, some out-of-the-box treatments that may help include endobronchial valves and bronchial coiling,” he said. “Walter Reed is a site testing for an endobronchial coil, a device that blocks the airways to the most diseased parts of lung. By keeping air from being trapped in those parts of the lung, it improves shortness of breath and lung function. Hopefully, these devices can provide relief in the future, but for now, they’re still being tested.”
Importance of Exercise
Beyond medical therapy, comprehensive care for COPD includes pulmonary rehabilitation with respiratory therapists and a structured exercise program. At Walter Reed, the program lasts 12 weeks, with encouragement to continue exercise and strength training. “One thing that’s clear: maintenance of physical activity in daily life goes a long way to slowing progression of symptoms and maintaining quality of life,” Perkins said.
Improving exercise tolerance is a major goal of therapy for managing stable COPD, according to the GOLD guidelines.
Aerobics and strength training help in a variety of ways, Perkins noted. Fatigue often plagues COPD patients and exercise increases energy levels and helps the body better use oxygen by strengthening the heart and cardiovascular system. Weight loss and increased muscle tone reduce the demand on the lungs. Sleep and symptoms of depression also improve with exercise, providing significant improvement in quality of life for many individuals with COPD.
In addition, weight-bearing exercises strengthen bones, which is particularly important for people with pulmonary impairment, according to research. Two VA studies have shown a very high correlation of bone disease in veterans with COPD and other lung diseases, though whether the weakening of bone is cause by use of inhaled corticosteroids, inflammation associated with the disease or other factors remains a matter of some debate.
In one study, 60% of 46 veterans referred to a pulmonary clinic at the VA Loma Linda Healthcare System in Loma Linda, CA, had positive dual-emission X-ray absorptiometry scans. Those patients with more severe disease were more likely to have osteopenia or osteoporosis. In the second study, nearly half of the more than 12,000 veterans with hip fractures that required surgery at the VHA from 1998 to 2005 had COPD. 2,3
Patients with more advanced disease may be put on oxygen therapy to combat chronic hypoxia, while lung transplantation or lung volume reduction surgery may be options for those who have severe symptoms despite maximal medical therapy.
- Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive pulmonary Disease. January 2014.
- Abstract 32409 High Prevalence Of Osteopenia/Osteoporosis In Patients Referred For Pulmonary Rehabilitation Type: Scientific Abstract Category: 15.06 – Pulmonary Rehabilitation: Patient Assessment (PR) Authors: K. Ellstrom, N.L. Specht; VA Loma Linda Healthcare System – Loma Linda, CA/US. ATS 2012 International Conference.
- Regan EA, Radcliff TA, Henderson WG, Cowper Ripley DC, Maciejewski ML, et al. Improving hip fractures outcomes for COPD patients. COPD. Published online Dec 28, 2012.