Key Facts for Pharmacists About Revised COPD Treatment Guidelines and the Need to Improve Medication Compliance
When the Global Initiative for Obstructive Lung Disease (GOLD) released their revised 2017 COPD treatment guidelines, they made some key changes that pharmacists should know about, but there’s a larger issue that’s more likely to affect your daily pharmacy practice—the significant prevalence of nonadherence to COPD therapies. Pharmacists are among the top influencers when it comes to boosting compliance, so once you know about the factors that impact adherence, you’ll be better equipped to counsel patients and improve medication outcomes.
Highlights of the GOLD Treatment Guidelines
The GOLD recommendations were developed by a collaboration of 22 COPD experts who reviewed research published through October 2016. Some of the basics remain the same. For example, COPD should be considered in any patient with dyspnea, a chronic cough, sputum production, and/or a history of exposure to risk factors. These are the primary indicators and risk factors:
- Dyspnea – may be progressive, persistent or worse with exercise
- Chronic cough – may be intermittent or unproductive
- Recurrent lower respiratory tract infections
- History of risk factors –
- Exposure to tobacco smoke
- Exposure to home cooking or heating fuel vapors and/or occupational dust and vapors
- Family history of COPD
- Childhood history of low birth weight or respiratory infections
The ABCD system, which categorizes patients according to disease severity and defines pharmacologic treatment algorithms, saw a major change—it no longer uses spirometry. The new guidelines define ABCD categories according to patient symptoms and the frequency and severity of exacerbations. While spirometry is always required to make a diagnosis—and it’s essential for monitoring progress in nonpharmacologic therapies—it has limited relevance for all first-line pharmaceutical choices except for roflumilast.1
The revised guidelines provide step-up and step-down therapeutic algorithms, which is a change from earlier GOLD guidelines that only focused on initial treatment. A brief overview of the recommendations include:2
- Group A (low risk, fewer symptoms) – Short- or long-lasting bronchodilator to reduce breathlessness; discontinue if symptoms improve.
- Group B – Initial therapy should be a long-acting bronchodilator. There’s no evidence to recommend one class of long-acting bronchodilator over another, so the choice depends on individual response. Should breathlessness persist on monotherapy, use of two bronchodilators is recommended.
- Group C – Initial treatment with a single long-acting bronchodilator; long-acting muscarinic antagonists (LAMA) are recommended as the first-line option. Persistent exacerbations may need a second long-acting bronchodilator, either LAMA, a long-acting beta2-agonists (LABA), or a combination of LABA with an inhaled corticosteroid (ICS).
- Group D (high risk, more symptoms) – LABA/LAMA combination yields better results than a single bronchodilator. LABA/LAMA is recommended over LABA/ICS. If exacerbations worsen, either escalate to LABA/LAMA/ICS or switch to LABA/ICS then add LAMA if necessary. Should exacerbations persist, consider adding roflumilast or macrolide (in former smokers) and/or stopping ICS to lower the risk of adverse effects.
The guidelines also include a thorough review of nonpharmacologic options. The most important part of any treatment plan is still smoking cessation, but other vital recommendations include exercise training, nutritional support, influenza and Pneumococcal vaccinations, pulmonary rehabilitation, oxygen therapy in patients with severe resting hypoxemia, and management of comorbidities.
Improving Patient Compliance with COPD Treatment Guidelines
The global prevalence of COPD is estimated to be around 10 percent, but age-standardized data in the United States shows wide variation between states, with rates ranging from 3 to 9 percent.3 Nonadherence to treatment is high across the board: 41.3 percent of patients don’t comply with inhaled treatments, while 57 percent don’t take their oral medications.4
Before pharmacists can help improve patient compliance, they need to know what issues factor into the problem. The first step is to be sure they understand when to use short-acting versus long-acting agents. Emphasize that they may be able to reduce treatment when symptoms improve, but that decision should only be made in collaboration with a physician.
Here’s a list of information about nonadherence that will help inform patient counseling:
- Patient education – Providing basic information about the pathophysiology of COPD, how medications work and their proper use is an essential first step toward better compliance. Take a conversational and empathetic approach—ask if they have any side effects or concerns about medication, which naturally leads into asking if they take medications less often than prescribed.
- Inhaler satisfaction – Patients who are satisfied with their inhaler—and know how to use it—are significantly more likely to comply with treatment. Qualities that influence satisfaction include durability, ergonomics, and ease of use. Primary care providers may not think to ask about this issue, so pharmacists should reach out to discuss potential problems. Ask about how easy it is to hold, whether it causes any mouth or throat irritation, if they need to breathe in too hard, or if they have a hard time breathing at the same time as pressing the inhaler.
- Financial concerns – Lack of money isn’t a comfortable topic for most patients, but let them know that you may be able to help them find a manufacturer’s coupon, enroll in a prescription plan, or talk with their physician about less expensive medication alternatives.
- Polypharmacy and/or a complex medication regimen – Find ways to simplify the medication schedule for these patients, whether it’s a simple pill box or compounding multiple agents into one medication. Be aware that non-adherent COPD patients are also more likely to be non-adherent with all of their medications.5
- Depression – In older adults, average monthly adherence to COPD maintenance medications peaked at 57 percent in the first month, then dropped to 35 percent within 6 months following a diagnosis of depression.6 This should be on your radar during counseling sessions.
On the flip side, it’s also important to be on the lookout for patients who overuse their COPD medication because they may need a change in therapy. A study of patients using short-acting beta-agonist bronchodilators found that only half of over-users were on maximal maintenance inhaler therapy.7
Outreach to COPD Patients Boosts Compliance and Quality of Life
The lack of adherence to a COPD regimen is almost unimaginable when you consider the consequences—struggling to breathe and hospitalization for respiratory therapy—not to mention that COPD is the third leading cause of death in the United States.8 Outreach efforts that ensure the choice of inhaler is individually tailored and improve treatment diligence can make a life-changing difference for the COPD patients that trust your expertise and depend on your advice.
Pharmaceutica North America provides prescription drug products and bulk active pharmaceutical ingredients, including fluticasone propionate, which is used in combination with salmeterol for COPD patients. Contact us today to talk about how we can help support your pharmaceutical needs.
- “COPD Guidelines Update Treatment, Management Options,” February 2017, http://www.medscape.com/viewarticle/875351 ↩
- “Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report,” January 2017, http://www.atsjournals.org/doi/pdf/10.1164/rccm.201701-0218PP ↩
- “Chronic Obstructive Pulmonary Disease (COPD): Data and Statistics,” May 2014, https://www.cdc.gov/copd/data.htm ↩
- “Improving Medication Adherence in Chronic Obstructive Pulmonary Disease: A Systematic Review,” October 2013, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4015036/ ↩
- “Overlap of Nonadherence to COPD Medications and Other Chronic Disease Medications,” January 2017, http://www.ajmc.com/newsroom/overlap-of-nonadherence-to-copd-medications-and-other-chronic-disease-medications ↩
- “Adherence to Maintenance Medications Among Older Adults with chronic Obstructive Pulmonary Disease: The Role of Depression,” September 2016, https://www.ncbi.nlm.nih.gov/pubmed/27332765 ↩
- “Overuse of Short-Acting Beta-Agonist Bronchodilators in COPD During Periods of Clinical Stability,” July 2016, http://www.resmedjournal.com/article/S0954-6111(16)30094-4/abstract ↩
- “Chronic Obstructive Pulmonary Disease (COPD),” July 2016, http://emedicine.medscape.com/article/297664-overview#a6 ↩