Chronic obstructive pulmonary disease (COPD) increasingly is viewed by clinicians as a systemic disease that is treatable, instead of a debilitating lung disease that offers few options for patients. To drive that point home, the VA and DoD recently updated their joint clinical practice guideline for the first time in more than seven years.

By Sandra Basu

WASHINGTON — With the care and management of chronic obstructive pulmonary disease (COPD) changing significantly over the last few years with advances in research and treatment options, the VA/DoD’s clinical practice guidelines (CPG) for the diagnosis and management of COPD underwent a makeover at the end of last year. The update is the first one for the CPG since 2007.

“The general theme was to try to drive home the point that COPD is not just a lung disease but more of a systemic disease that is very treatable. That was in the previous guideline, but that is still a relatively new concept for a lot of people,” said Army Lt. Col. John Sherner, MD, program director of the National Capital

Consortium’s pulmonary and critical care medicine fellowship at Walter Reed

National Military Medical Center, told U.S. Medicine. A staff physician in the pulmonary and

critical medicine department at Fort Belvoir Community Hospital in Virginia,  Sherner also served as a COPD Guideline Work Group co-chair from DoD.

Lt. Col. John Sherner, a physician at Fort Belvoir Community Hospital and Walter Reed National Military Medical Center, discusses a lung scan with a colleague at his Fort Belvoir Community Hospital office (photo courtesy of FBCH).

The effort to update the CPG was a particularly important task, given the impact of COPD. It is a major health problem worldwide, and veterans are at higher risk of COPD than the general U.S. population.

Within VA, COPD is about four times more prevalent than in the general population, largely because of tobacco exposure and the high rate of current and past tobacco use.

Although the VA already treats about 1 million COPD patients, that number is expected to increase. A report from the House Committee on Veterans’ Affairs estimated that prevalence of airflow limitation is 33%-43% among VHA patients, indicating even higher rates of undiagnosed disease.

Marta Render, MD, who served as a co-chair of the work group from VA, pointed out that under-diagnosis or a late diagnosis in veterans is a challenge.

 “The problem with that is the most effective strategy is prevention, which means early on quit smoking,” said Render, director of the VHA National Program Director for Pulmonary, Critical Care and Sleep.

One way VA has been working to improve diagnosis is by offering spirometry testing in community-based outpatient clinics so patients do not have to always travel to a VAMC to be screened.

“They can get it in the clinics, and we think that will help in the diagnosis,” Render told U.S. Medicine.

COPD Guidelines

Render and Sherner both said the COPD CPG addresses a range of important topics to help primary care providers provide better care, including information on rehabilitation.

“It is increasingly clear that one of the most important things that folks can do is exercise,” Render pointed out. “The more they do, the more they can do, and so we think that self-management strategy is really an important element, because we know that adherence to evidence-based practices by patients is even more limited than the adherence to evidence-based practices by doctors.”

Another important element of the updated CPG is a change in the recommended duration of steroid and antibiotic therapy for acute exacerbations of COPD, Sherner said.

The strongest recommendations are for a course of systemic corticosteroids, preferably oral, of 30-40 mg prednisone equivalent daily for five to seven days and a five-day course of an antibiotic. First-line antibiotics could include doxycycline, trimethoprim/sufamethoxazole, a second-generation cephalosporin, amoxicillin, amoxicillin/clavulanate or azyithromycin, according to the guidelines, which suggest reserving broader spectrum antibiotics for patients hospitalized in intensive care units or those especially susceptible to healthcare-associated infections.

Render said the guidelines also include new information about the acute management of COPD in the hospital that shows that noninvasive ventilation can reduce mortality as well as length of hospital stay.

When it comes to the management of patients with COPD in the outpatient setting, Render noted that the updated guideline recommendations take into account evidence on the benefits of long-acting bronchodilators for patients with confirmed, stable COPD who continue to have respiratory symptoms.

“The previous guidelines were written largely in 2006. They didn’t include data from new trials that identified the benefit of long-acting bronchodilator agents in reducing exacerbations,” she explained.

The guidelines differ somewhat from other documents, such as the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD); for example, the VA/DoD CPG does not have recommendations regarding utilization of existing clinical classification systems at this time.

“None of them provide sufficiently valid categories to be useful alone to direct decision-making regarding treatment or prognostication,” the VA/DoD CPG explains.

The VA/DoD CPG recommends instead that patients with COPD be classified into two groups based on the severity history of their disease. Render suggested that is less complex than \ the GOLD guidelines.

“These guidelines suggest that primary care doctors divide their group into those who have had exacerbations and those who haven’t, and to make sure that those who have had exacerbations are on long-acting agents and if they continue to have exacerbations they explore the contribution of other comorbid diseases,” Render said.

Updating Guidelines

Sherner said the working group sought to produce a product that would meet the needs of primary care providers, adding, “We wanted to review all of that evidence and put it together in a concise and easily applicable format for people to have as a reference.”

One strength of the guideline, he noted, is that the working group was composed of experts in the field as well as a multidisciplinary team.

“We were able to see what the evidence supported and then directly consider how applicable that was to our DoD and VA population,” he said.

As part of the work to update the CPG, evidence questions (KQs) were first identified.

“The KQs were developed specifically to address the current state of COPD treatment and management and significant scientific developments since the 2007 guideline. The questions selected were of high priority for the VA and the DoD key populations,” the COPD CPG stated.

The work group then focused “largely on developing new and updated recommendations based on the evidence review conducted for the priority areas addressed by the KQs.”

“In addition to those new and updated recommendations, the Guideline Work Group considered the current applicability of other recommendations that were included in the previous CPG on management of COPD, published in 2007, subject to evolving practice in today’s environment,” the document states.

Not all of the 2007 CPG were updated, however.

“For instance, though vitally important, an evidence synthesis was not performed for the effects of various methods of smoking cessation. This is because the authors/editors felt that the methods used for smoking cessation and their effect on COPD in general are well-established and addressed elsewhere,” the new guidelines explain.