Initial Choice of Pharmacologic Therapy in COPD

A 68-year-old man with a 15-year history of hypertension and dyslipidemia, as well as a 45 pack-year history of cigarette smoking, currently smoking one pack per day, was recently diagnosed with COPD. His FEV1 to FEC ratio is less than 0.7, and his FEV1 is 48% of predicted. He reports two COPD exacerbations in the past year, both treated as an outpatient, and also mentions "I need to pace myself or I get short of breath even if I walk up just a flight of stairs. I can't do any work in the yard anymore." Per current treatment recommendations, which of the following is advised for his COPD maintenance therapy?

A. SABA as needed for shortness of breath

B. Daily use of an ICS LABA

C. As needed use of a LABA for symptoms

D. Scheduled use of an inhaled LABA/LAMA

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Transcript

Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education

Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.

Margaret Fitzgerald: A 68-year-old man with a 15-year history of hypertension and dyslipidemia as well as a 45 pack-year history of cigarette smoking currently smoking one pack per day was recently diagnosed with COPD. His FEV1 to FEC ratio is less than .7 and his FEV1 is 48% of predicted. He reports two COPD exacerbations in the past year, both treated as an outpatient, and also mentions, quote, I need to pace myself or I get short of breath even if I walk up just a flight of stairs. I can't do any work in the yard anymore. 

Per current treatment recommendations, which of the following is advised for his COPD maintenance therapy?

A. A SABA as needed for shortness of breath

B. Daily use of an ICS LABA

C. As needed use of a LABA for symptoms

D. Scheduled use of an inhaled LABA/LAMA

The correct answer is D. Scheduled use of an inhaled LABA/LAMA.

Where should we start? First, determine what kind of a question this is given that we're provided with the patient's diagnosis and actually a good deal of assessment data and then asked which therapy would be most appropriate. This is a plan/intervention question. 

Some background information. COPD is considered to be a preventable but also a treatable disease characterized by airflow limitation that's not fully reversible even with the use of an inhaled bronco dilator. In contrast, asthma is characterized by airflow limitation that is more reversible with bronco dilator use. In other words, the airways are fairly fixed in their obstruction in COPD, not so fixed in asthma. The pathophysiology of COPD involves inflammation and narrowing of the peripheral airways that lead to a characteristic decrease in lung function. This loss of small airways in addition to airway narrowing is a significant contributor to uh airflow limitation and air trapping. In uh COPD airflow limitation is usually progressive. There are a couple of reasons for that. One is all of us have more airflow limitation as we get older. 60 year-old 70 year-old has more airflow limitation even if they don't have COPD they don't have asthma they've never smoked than let's say a 20-year-old so you layer aging on top of the pathophysiology and you've got a real problem here on top of that in this particular case study we're dealing with somebody who is still smoking so he is still shall we say insulting his airways with a significant irritant. The clinical presentation of COPD typically includes symptoms of recurrent dyspnea, chronic cough, and persistent sputum production. And that's particularly noted in the absence of respiratory tract infection. On top of that, these signs and symptoms get worse when somebody has a respiratory tract infection when they also have COPD. Suffice to say, the greatest risk for COPD development is tobacco use, but air pollution is also a significant contributor and the select genetic components are often implicated and that gets a little bit beyond the scope of this presentation, but the gold COPD guidelines do a great job of getting into that. And when you do need to test for these genetic components, that's unlikely to crop up on boards. But even at baseline, not everybody who smokes develops COPD. There is probably some unknown genetic factor that has yet to. be identified in kind of the more day-to-day development of COPD. 

A working diagnosis of COPD should be considered in any patient who has these persistent COPD symptoms such as the progressive dyspnea, chronic cough or sputum production and or a history of risk factors such as tobacco use. We have all of this in this patient. But on top of that, we also have the parameters that give us the diagnosis of COPD, which is the altered FEV1 and the altered FEV1 to FEC ratio of below .7. I have another podcast that goes into making the diagnosis of COPD and what parameters you look at. This particular podcast is focusing in though of course on the pharmacologic therapy of a person with COPD. So the pharm-therapy can be helpful in minimizing COPD symptoms, improving activity tolerance, and preventing exacerbations. To reflect one more time on the guy that we're talking about here, he's telling you, I can't get up a flight of stairs without struggling. I can't do yard work anymore. he is telling you that his activity is limited due to COPD. Unfortunately, there really is no definitive evidence that the commonly used COPD meds will alter the long-term decline in lung function. However, preventing COPD exacerbation is incredibly important because the average person who has a COPD exacerbation has marketkedly limited activity for about six weeks. In other words, even if their activity was not that robust for about 6 weeks, they move around even less. And I think you would agree with me, you seldom run into a patient with COPD who isn't older and doesn't have some other significant comorbidity going on. So now you take an older person with some comorbidity, they come down with a COPD exacerbation and now they move less for about 6 weeks. takes them literally about six weeks to get back to their baseline, which might not have been that good in the first place. Can you see how this ends up being a real issue? Almost like a a spiraling down where people can get very debilitated as a result of a COPD exacerbation. 

The backbone of pharmacologic therapy for COPD is a variety of inhaled meds including bronchodilators and select anti-inflammatory medications. This is a little bit like looking at meds for diabetes or the like. You look at it and you go, "Okay, which one do I even start with?" I'm going to give you some hints on that. And the choice of the therapy is dictated by a number of factors including COPD symptom severity, frequency of exacerbation, and measurable parameters such as FEV1. The gold COPD guidelines available at goldcopd.org provide detailed information on this issue. With this as a little bit of background, let's take another look at the question.

A 68-year-old man with a 15-year history of hypertension and dyslipidemia and a 45 pack-year cigarette smoking history currently smoking one pack per day was recently diagnosed with COPD. FEV1 to FEC ratio is less than .7 and he has an FEV1 of 48% of predicted. He reports two COPD exacerbations in the past year, both treated as an outpatient, and reports, uh, quote, I need to pace myself or I get short of breath even when I walk up just a flight of stairs. I can't do any work in the yard anymore. Close quote. Per current recommendations, which of the following is the best choice of his COPD maintenance therapy? 

Now before we dive into the answers, just a couple of things to take a look at here. The question specifically asked about maintenance therapy. Did everyone catch that? Yes. Maintenance therapy in COPD is aimed at preventing symptoms and preventing exacerbations. And this patient has had frequent exacerbations, even if they were treated as an outpatient, even if he wasn't sick enough to go into the hospital. This is significant. It's telling me he's got a lot of airway inflammation. They need to help give him something that's going to help calm that down. Particularly since he still smokes and he's unable to do work that at one time he did all due to symptoms. remember he said, "I can't do work in the yard anymore." And would I want to pursue that a little bit more with this patient on quantifying what he means by what kind of yard work did he do in the past versus what is he unable to do now? Would I want to do something like put him through answering the questions on the CAT questionnaire which quantifies degree of debility with COPD? Absolutely. Absolutely. But as I've said a bazillion times on these podcasts, the boards will give you enough information to answer the question, but not one micron more. Okay. We also have to remember is FEV1 is quite low and so that puts him in the category of severe COPD. There's a little bit more to doing the classification than that, but that's enough to get us going. And as I've said, every word in the question is important. 

So, back to our patient. Option A, a SABA as needed for shortness of breath. So, in other words, PRN albuterol use. This is incorrect. A SABA such as a short acting beta 2 agonist. Albuterol obviously the most commonly used is part of COPD therapy to relieveacute symptoms. He probably will be given a prescription for a SABA for acute shortness of breath but this question asks about maintenance therapy. So choosing a SABA even though yes he should have access to one of those it does not answer the question correctly. 

B daily use of an ICS LABA. The use of inhaled corticosteroid in individuals with COPD increases pneumonia risk. While that risk is fairly modest given that people with COPD fare so poorly when they develop pneumonia only certain patients are considered to be ICS candidates. We don't have enough information on him to know whether an ICS would be a good addition or not to be honest with you. Well, of course, if you're thinking asthma instead of COPD, this might be the best answer. In fact, it would be the best answer here. But we're not talking about asthma. We're talking about COPD. In addition, people with COPD who qualify for inhaled corticosteroid therapy will typically also used an inhaled LAMA. And that's the triple therapies that you often will see somebody on who has COPD in ICS LABA/LAMA therapy. 

Option C as needed use of a LABA for symptoms. In COPD timed LABA use like by the clock can be used to prevent shortness of breath but it is not used BRN for symptoms. 

Option D, scheduled use of an inhaled llama LABA/LAMA. This is of course the correct answer. The llama also known as long acting muscarinic antagonist and these are drugs that have the ium suffix like tiotropium that happens to be spiriva plus a long acting beta 2 agonist a LABA. These are drugs that have the teral suffix. An example of that would be for formoterol. These provide bronco dilation for people with COPD and a very slim part of the population of people with asthma. But it provides people with broncodilation from two different mechanisms. A very common example of a LABA/LAMA combination is the trade name drug anoro ellipta. And what I'm going to do is tell you go take a look at the generic names of what's in anoro ellipta. It's almost unpronounceable for the llama part of it. So I'm going to let you do that and I'm not going to embarrass myself. So aside from the dual bronco dilation that I just mentioned, LAMA use is also associated with reduced risk for COPD exacerbation but without the pneumonia risk that we see with inhaled corticosteroid use. And this drug combination, the llama LABA/LAMA combo, is often used as the contemporary backbone of COPD therapy. Keep that in mind as you are prepping for boards. 

So key takeaway, knowledge of disease pathophysiology, linking that up with drug mechanism of action plus add in best evidence. This guides medication choices. This case is a great example of these principles. 

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