Primary Care Management of Asthma and COPD

Once confirmation of an asthma diagnosis is made, most primary care physicians can manage the condition and need refer only challenging cases to a pulmonologist.

“Most asthma is manageable and not difficult to control,” said Sola Olopade, MD, MPH, FACP, FCCP, professor of Medicine at The University of Chicago, during a presentation at the American College of Physicians Internal Medicine 2014 annual meeting held in Orlando, FL.

“It’s important to take a very good and detailed history,” Olopade added. “Every patient is different.”

Olopade encouraged physicians to ask about occupational exposures to irritants; the use of medications, including aspirin and other anti-inflammatory drugs and antihypertensives; and household pets, including birds, which patients often forget to mention.

“Most patients are poorly controlled, because [they] haven’t identified the factor making the asthma worse,” he said.

Following the history, he suggested obtaining spirometry. A methacholine challenge test may be helpful, except with anticipated exercise-induced asthma. The best way to check for exercise-induced asthma is to assess FEV1 (forced expiratory volume in 1 second) 20 minutes into the exercise session.

When monitoring effectiveness of therapy, Olopade said he pays the most attention to nighttime symptoms. If the patient does not respond to asthma therapy, extrapulmonary conditions, such as gastroesophageal reflux disease or rhinitis, should be considered and treated. Physicians should also treat sleep apnea, which can worsen asthma symptoms.

For patients who continue to worsen despite initial treatment, Olopade encouraged the audience to explore what might be making symptoms worse and not simply to increase the level of treatment. He advised that they delve into the patient’s history to determine what might contribute, and offer suggestions for mitigation; for instance, patients may need professional help to rid a home of mold.

For patients with moderately severe asthma, he suggested trying the long-acting muscarinic receptor antagonist tiotropium, in conjunction with inhaled corticosteroids.

“Asthma symptoms and pulmonary function can be well controlled by the addition of tiotropium as an alternative to salmeterol,” Olopade said. “The effectiveness is comparable.”

The anti-IgE medication Xolair makes physiologic sense and can mitigate the allergic mechanism that drives asthma and prevents exacerbations, he said. However, he recommended reserving it for people with severe allergic asthma uncontrolled on aggressive standard treatment and who frequently need steroid bursts, those with an elevated IgE level, and patients who are steroid dependent.

“Don’t use it as an early intervention,” he advised.

Bronchial thermoplasty, in which the smooth muscle in the airway is burned during bronchoscopy, has been effective in improving symptoms of moderate to severe asthma. Adverse events, such as mucous plugs are manageable. Studies have shown improvement in asthma control and quality of life but not in improvement to peak flow and FEV1.

“The fact is, just because we can do it, doesn’t mean we should do it for everyone,” Olopade cautioned.

Olopade also discussed management of chronic obstructive pulmonary disease (COPD). Goals include reducing symptoms, improving exercise tolerance and health status. In addition, physicians are focusing more on patients’ quality of life and reducing the risk of exacerbations, which means decreasing exposure to risk factors, such as smoking. Taking care of a patient who continues to smoke presents a challenge for physicians, he said, recommending smoking cessation programs. Pulmonary rehabilitation proves helpful for many patients.

Roflumilast works well as an adjuvant therapy in patients with severe COPD and chronic bronchitis who can tolerate it. He said it should not be the default medication for all patients. Gastrointestinal side effects, with associated significant weight loss and loss of muscle mass, hinder its successful use.