COPD Exacerbations and Treatment Selection

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The MD Magazine Peer Exchange “Expanding Treatment Options: The Latest Developments in COPD Therapy” features a panel of physician experts discussing key topics in COPD therapy, including risk factors, personalized treatment, preventive measures, new combination therapies, and more.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

• Byron Thomashow, MD, professor of medicine at Columbia University Medical Center, medical director at the Jo-Ann LeBuhn Center for Chest Disease at New York-Presbyterian Hospital, and chairman of the board of the COPD Foundation
• Neil R. MacIntyre, MD, clinical chief of the Pulmonary/Critical Care Division, medical director of Respiratory Care Services, and professor of medicine at Duke University School of Medicine
• Barry J. Make, MD, director of Pulmonary and Respiratory Care for National Jewish Health and professor of medicine at the University of Colorado School of Medicine
• Nicola A. Hanania, MD, MS, associate professor of medicine and director of the Asthma and COPD Clinical Research Center at Baylor College of Medicine

According to Thomashow, “There is data out there, the ECLIPSE study for example showed that even in the most severe patients with COPD, only less than half of them were frequent exacerbators. That means that half of these people with the most severe COPD are not frequent exacerbators. One could make the argument that those people don’t need the inhaled steroid component. That could be argued in multiple ways, I understand, but you could make that argument. And yet I’ve seen data that as many as 60% of the COPD patients out there, they’re already on triples.”

“We moved almost from the single agent to triples; how difficult is it going to be to redo that? I think many of us believe that a LAMA/LABA combination may very well be a mainstay of therapy for a lot of patients with COPD who are not exacerbated, maybe even for the exacerbators for that matter,” Thomashow continued.

“But what do we do now because we’ve missed that step and how difficult is it to take a step backwards? The primary care docs and pulmonologists are going to say, ‘Why should I do that? It can’t be better than triple because they’re already on those medicines on the triple. And if I’m wrong, if this is asthma, they would benefit from the inhaled steroid. If this is ACOS, they would benefit from the inhaled steroid. What is the advantage?’ How can we now restart the clock as opposed to just going forward?”

Make said a study published in the New England Journal of Medicine earlier this year called the WISDOM trial “put everybody on triple therapy and then withdrew the inhaled steroid. Now, they withdrew it slowly over 12 weeks which is an interesting way to do it, and the study which was a year duration found that there was no significant change in the exacerbation rate as the major outcome.”

“There was an average of about a 45 ml decrease in FEV1, so you’re getting it but not in all patients so you need to look at that 45 ml’s is not that great. It’s not considered the minimal clinical important difference, but if that was to persist or get larger over a longer period of time, it would be very important,” Make said.