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Addressing unmet patient needs in COPD treatment
A roundtable of respiratory experts convened in Boston, MA to explore how to address challenges associated with the treatment of patients with COPD. Over the course of 2018, the Philips Sleep & Respiratory Newsletter plans to revisit further some of these topics, e.g. the panel’s “guiding principles for use of nebulized Long-Acting Beta2-Agonists in COPD ” formulated upon review of evidence from clinical trials and practice experience.1 The clinical luminaries covered a range of topics regarding the role of aerosol delivery in COPD, including the concept of personalization when it comes to selection of an inhalation-based COPD therapy. The role of a patient’s cognitive and physical ability and poor adherence to medication2 was explored, and root causes identified.
The device factor
The panel noted a number of clinical insights around this topic in its post-roundtable report published in The Journal of the COPD Foundation.1 The implications of not using handheld medication devices properly was one area of focus. Issues with patient operation of a handheld device has been linked poor symptom control and a need for acute care.3 This problem appears to be quite common. One study indicates that over 94% of patients committed “errors related to poor technique” (despite indicating they knew how to properly use the device).4
The panel went on to consider the myriad of factors that may impact the patient’s ability to properly operate a handheld device. Cognitive state and physical ability are paramount. A variety of associated factors as socioeconomic status, age and education-level were also identified as potentially playing a role,1 depending of course upon the individual.
Poor inhaler technique and device misuse*
| Older age (P=0.008) | Lower education level (P=0.001) |
| Poor vision (P=0.004) | Lack of instruction (P<0.001) |
Devices and the COPD patient
Many COPD patients are challenged with co-morbidities that affect their health5. Progressive conditions, such as bone disease or rheumatoid arthritis, can constrain a patient’s ability to work an inhalation device. 1 Further, COPD and cognitive degeneration may be correlated. A study of 1,425 of patients (1,055 with normal cognitive function at baseline; age range 74-83) showed that a diagnosis of COPD increased the risk of mild cognitive impairment by 83%.6
Given these learnings, the panel discussed common devices on the market. Certain handhelds, such as dry powder inhalers (DPIs) require a number of user interactions, and may not be ideal for the COPD patient. Also, evidence suggests that that peak inspiratory flow rate tends to decline in COPD patients over time, limiting the efficacy of DPIs that may require a minimum Peak inspiratory flow to optimize medication delivery.7a-c.
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A sampling of conclusions offered by the panel:
No such thing as a “one-size fits all” device ideal for individual COPD patients.
The panel promotes evaluation of physical and cognitive skills, as well as consideration of socioeconomic factors such as the home care and/or living environment.1
”Affirmation of patient knowledge” does not necessarily translate to proper use of inhalation devices.
The panel discussed the merits of new and practical method (such as the teach-back) either after recovery from an exacerbation, or where applicable, within two weeks of a hospital discharge.1
Given potential challenges in proper use of a pMDI or DPI, a nebulizer may be a more appropriate choice.
for “transitional care and home-bound or long-term care-bound patients.1
The panel noted that further research is called for. All panel members from the roundtable meeting were involved in the development of the manuscript, which only scratch the surface of the work.
*Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011. 105(6): 930-938. doi: http://dx.doi.org/10.1016/j.rmed.2011.01.005. Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. J Gen Intern Med. 2011. 26(6): 635-642. doi: http://dx.doi.org/10.1007/s11606-010-1624-2) 1About the study: Journal of the COPD Foundation. Published on The COPD Foundation owns the copyright to all content in the JCOPDF, unless otherwise noted. Funding for the live roundtable meeting held on August 23, 2015 in Boston, Massachusetts and medical writing support was provided by Sunovion Pharmaceuticals, Inc. Panel authors: Robert A. Wise, MD Russell A. Acevedo, MD2 Antonio R. Anzueto, MD Nicola A. Hanania, MD, MS Fernando J. Martinez, MD Jill A. Ohar, MD Donald P. Tashkin, MD 2Ingebrigtsen TS, Marott JL, Nordestgaard BG, et al. Low use and adherence to maintenance medication in chronic obstructive pulmonary disease in the general population. J Gen Intern Med. 2015. 30(1): 51-59. doi: http://dx.doi.org/10.1007/s11606-014-3029-0 3Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011. 105(6): 930-938. doi: http://dx.doi.org/10.1016/j.rmed.2011.01.005 4Souza ML, Meneghini AC, Ferraz E, Vianna EO, Borges MC. Knowledge of and technique for using inhalation devices among asthma patients and COPD patients. J Bras Pneumol. 2009. 35(9): 824-831. 5Chatila WM, Thomashow BM, Minai OA, Criner GJ, Make BJ. Comorbidities in chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2008. 5(4): 549-555. doi: http://dx.doi.org/10.1513/pats.200709-148ET 6Singh B, Mielke MM, Parsaik AK, et al. A prospective study of chronic obstructive pulmonary disease and the risk for mild cognitive impairment. JAMA Neurol. 2014. 71(5): 581-588. doi: http://dx.doi.org/10.1001/jamaneurol.2014.94 7a-c Jarvis S, Ind PW, Shiner RJ. Inhaled therapy in elderly COPD patients; time for re-evaluation? Age Ageing. 2007. 36(2): 213-218. doi: http://dx.doi.org/10.1093/ageing/afl174. Quinet P, Young CA, Heritier F. The use of dry powder inhaler devices by elderly patients suffering from chronic obstructive pulmonary disease. Ann Phys Rehabil Med. 2010. 53(2): 69-76. doi: http://dx.doi.org/10.1016/j.rehab.2009.11.001. Mahler DA, Waterman LA, Gifford AH. Prevalence and COPD phenotype for a suboptimal peak inspiratory flow rate against the simulated resistance of the Diskus® dry powder inhaler. J Aerosol Med Pulm Drug Deliv. 2013. 26(3): 174-179. doi: The research was publish in the Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation (https://journal.copdfoundation.org/jcopdf/id/1132/Guiding-Principles-for-the-Use-of-Nebulized-Long-Acting-Beta2-Agonists-in-Patients-with-COPD-An-Expert-Panel-Consensus). Retrieved Dec1, 2018