Q&A: Proactive Treatment Important for COPD Management

Alpesh Amin, MD, a specialist in hospital medicine at UC Irvine Health, said caring for patients with chronic obstructive pulmonary disease (COPD) requires effective maintenance therapy and management of acute exacerbation episodes. He added that is also demands a proactive approach to making the right diagnosis, matching prescribed therapies to a patient’s risk and disease state, and educating patients about using drug administration devices properly.

Dr. Amin recently discussed the importance of being proactive instead of reactive when treating patients with COPD and said providers who do so have the potential to make a significant positive impact on this debilitating disease.

Why is COPD so challenging to treat?

There are a number of reasons. The first involves making an accurate diagnosis. That sounds basic, but it’s a real issue. Estimates suggest 30% of COPD cases are not diagnosed accurately—the disease is overdiagnosed, underdiagnosed, not diagnosed, or should not have been diagnosed in the first place. The second main challenge involves risk stratifying patients based on where they are along the spectrum of their chronic disease so they can be managed according to guideline-directed approaches.

Unfortunately, among the top five disease states that contribute to mortality, COPD is the only one that’s increasing, not decreasing, mortality rates. Medicare has also added COPD to its list of readmission penalties, so health systems will earn less if patients end up back in the hospital after initial treatment. It’s clear that there is a need and opportunities to do a better job in diagnosing and managing the disease.

What are the keys to treating patients with the disease?

Patients who are hospitalized with suspected COPD are stabilized and discharged with the hope that primary care physicians, pulmonologists, or other healthcare providers would take over their care in an aggressive way. Regardless of where patients enter the health system—through the emergency department or ambulatory clinic—providers need to be more proactive in their management approach.

Patients must be put on the appropriate therapy based on their risk and their score on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. Gold criteria are updated every few years, so it’s important to stay current on the guidelines. Patients’ disease risk must be constantly assessed and managed accordingly.

To see what can be done to reduce readmissions among high-risk patients, go to page 2.

What can be done to reduce readmissions among high-risk patients?

Patients at high risk of readmission should be put on medications that have been shown to impact rehospitalization. For example, Roflumilast has been shown to reduce the number of rehospitalizations in certain types of patients, depending on their Gold criteria and how many hospital admissions they’ve had over the course of a year. However, it’s intended for use during the disease maintenance phase, not when patients are experiencing acute exacerbations.

Patients need to be managed through the acute exacerbation phase and then given the medication at the time of discharge or on an outpatient basis. Proper delivery of the medication is also an important factor and demands educating patients and their at-home caregivers about the administration devices they’re prescribed. It’s also important to for providers to consider which devices are best suited for specific patients. For example, it doesn't make sense to give an inhaler to patients with bad rheumatoid arthritis of the hands. It’d be best to prescribe a nebulizer in those cases.

What are the best ways to manage COPD medications?

The care team must identify patients who need antibiotics, steroids, or long-acting bronchodilator combinations (LAMA/LABA), and proactively decide which of those therapies is appropriate. These patients must be closely followed and receive continual monitoring to ensure they’re using drug administration devices appropriately so medications are effectively delivered to the lungs. After discharge from the hospital, patients should receive follow-up phone calls within 3 to 4 days to ensure they’re complying with prescribed medications and be seen by their next provider within a week. Providers need to be proactive with patients who are not responded to medication as expected and bring them back into the clinic for further care so the disease doesn’t progress to the point where hospital and ED resources are needed.

How can pharmacists contribute to a team-based approach to caring for these patients?

There’s a need for a more systematic, team-based approach to the management of COPD and its comorbidities in order to limit exacerbations. Pharmacists can manage formularies to ensure patients have access to appropriate medications. They can conduct medication reconciliations, ensure patients have access to needed therapies, and intervene if patients’ health plan formularies don’t accept the medications they’re prescribed. They can also serve as valuable resources for prescribers in determining which medications are effective and appropriate when patients enter exacerbation states. It’s valuable when pharmacists round with physicians and case managers in a multi-disciplinary approach to managing COPD. When rounding, pharmacists learn about patients’ health histories and contribute as part of the patient care team. Pharmacists might someday evaluate and monitor patients in outpatient clinics to make sure they’re on appropriate medications and using drug delivery devices properly.

—Dan Cook

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