New COPD guidelines offer more specific suggestions

The American Thoracic Society (ATS), at its recent 2004 International Conference in Orlando, Fla., announced the release of guidelines on chronic obstructive pulmonary disease (COPD). The guidelines, entitled "Standards for the diagnosis and treatment of patients with chronic obstructive pulmonary disease," were developed by ATS and the European Respiratory Society (ERS) as an update to their 1995 position papers.

Said Nicola Hanania, M.D., director of Adult Asthma Clinic, Ben Taub General Hospital, department of medicine, ATS and ERS agreed the guidelines required updating "in order to account for the recent advances in our understanding of COPD's effects on the lungs. The new guidelines stress the complexity of COPD because it is not just a disease of bronchoconstriction as we once thought. Inflammation plays a large role in the disease, and this changes all of the treatment algorithms." These revisions also allowed ATS and ERS to create an evidence-based document.

Although ATS and ERS recognize the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines that were released in 2003 by the National Heart, Lung, and Blood Institute and the World Health Organization, they felt the GOLD initiative was too broad in certain areas. The ATS and ERS chose to add to their guidelines more specific recommendations on oxygen therapy, pulmonary rehabilitation, non-invasive ventilation, surgery, air travel, sleep, and end-of-life issues. They also included an emphasis on the importance of smoking cessation, due to the effects of smoking on lung function.

COPD is the fourth-leading cause of death in the United States. COPD is a progressive condition characterized by the presence of airflow obstruction due to excessive mucus secretion into the bronchial tree. It is caused by bronchoconstriction and inflammation of the bronchioles, narrowing of airways due to fibrosis, and metaplasia of the bronchiolar epithelium. Tobacco smoking is the most important risk factor for COPD, although risk factors also include occupational exposures, socioeconomic status, and genetic predisposition. Due to a lack of symptoms occurring with mild disease, most patients do not realize their lung function is declining until lung damage becomes extensive. Less than 50% of individuals with COPD have been diagnosed by a physician.

Nearly 20 million Americans suffer from COPD. Over the past 20 years, COPD mortality in females has more than doubled. The Third National Health & Nutrition Examination Survey (NHANES III), conducted between 1988 and 1994, reported a prevalence of COPD, for individuals aged 25-75 years, as 6.9% for mild COPD and 6.6% for moderate COPD. The surveyors estimated that among Caucasian males, 14.2% of smokers, 6.9% of ex-smokers, and 3.3% of never-smokers suffer from COPD. The prevalence among Caucasian females was 13.6% in smokers, 6.8% in ex-smokers, and 3.1% in never-smokers.

Despite the excessive morbidity and mortality associated with COPD, the level of awareness about the disease is minimal. According to Hanania, if he "went out on the street and asked if people knew what COPD was, very few people would know. Yet, most people would know about diabetes and asthma." The new COPD guidelines are available on the ATS Web site: www.thoracic.org . By making the guidelines Web-based, rather than in print, ATS hopes to improve awareness about COPD. Along with providing patient information and question-and-answer sections, the Web site allows the reader to query for answers to other questions. For professionals who wish a written copy of the guidelines, they are downloadable from the Web site of the European Respiratory Society: www.ersnet.org .

Hanania stressed that the "guidelines are intended for all health professionals." He hopes pharmacists would increase their counseling role to both physicians and patients. Although he is aware that physicians are often hesitant to take advice, he feels pharmacists and physicians should work collaboratively.

According to Hanania, "Physicians often do not know how or when to use certain medications, and pharmacists can raise their awareness." He also hopes pharmacists would help identify problem patients.

"Many patients with COPD also have more than one comorbid condition. These patients have very complex medication regimens to follow. The pharmacist can work with the patient to understand how to use inhalers and to promote smoking cessation. The pharmacist can also notify the physician that the patient may be experiencing difficulties with his regimen," Hanania suggested.

Whether working with physicians or patients, the pharmacist should be aware of the treatment guidelines for COPD, Hanania advised. With the discovery of inflammation's role, the stepwise treatment of COPD has changed. Initial treatment with a bronchodilator is recommended, followed by an anti-inflammatory agent. The pharmacist should also stay abreast of new agents as they come to the market, he added.