Back Back
COPD Diagnosis and Treatment QA
Expert Answers to Key Questions on Diagnosing and Managing COPD

Released: July 24, 2024

Expiration: July 23, 2025

Mark H Gotfried
Mark H Gotfried, MD
Activity Information

Activity

Progress
1
Course Completed
Continue
Key Takeaways
  • Inhaled corticosteroids should be considered in addition to LABA/LAMA therapy in patients with frequent COPD exacerbations and a blood eosinophil count of 300 or greater.
  • Low-dose CT is recommended to screen patients for lung cancer only in those with COPD due to smoking.
  • When choosing an inhaler device, carefully consider patient specific characteristics, including cognition, dexterity, coordination, access, and medication adherence and persistence.

In this commentary, Mark Gotfried, MD, answers audience questions from the live MEDX Primary Care Regional Conference Series on June 22, 2024, on the latest research and 2024 GOLD Report guidance for diagnosing and managing COPD—including best practices—to support your clinical practice in the primary care setting.

When is it best to recommend low-dose CT (LDCT) for lung cancer screening in patients with COPD? In addition, how do you balance the use of LDCT to avoid risk for radiation or cancer?

In this instance, you need to consult the guidelines, and there are multiple guidelines from pulmonary- and primary care–dedicated societies. According to the recently updated GOLD Report, LDCT is recommended annually for lung cancer screening in patients with COPD due to smoking. Of note, for any patient with COPD that is not due to smoking, LDCT is not recommended as the evidence is insufficient to support its use in this setting. Screening can be stopped once patients have stopped smoking for 15 years or present with a health condition that limits their life expectancy or ability to have curative surgery. The guidelines clearly report that the benefit of preventing cancer outweighs the risk of LDCT.

When would you recommend using inhaled corticosteroids (ICS) in a COPD regimen?

The guidelines recommend the use of an ICS in addition to bronchodilator therapy if a patient has consistent COPD exacerbations and a blood eosinophil count of 300. Likewise, if a patient with COPD is on dual bronchodilator therapy (long-acting beta agonist [LABA] and long-acting antimuscarinic antagonist [LAMA] combination) with consistent exacerbations and a blood eosinophil count of 100 or more, healthcare professionals should consider the addition of an ICS. The only time that you should not consider adding an ICS is if their blood eosinophil count is less than 100.

I would not base this decision on a single measurement. Rather, you should measure patients’ eosinophil count more than once to assess this as a continuum. The other caveat to consider is accurately measuring blood eosinophil count among patients on systemic corticosteroids. You will need to wait a few weeks after they have started steroids as these agents will impact their measurement. For example, a single course of oral steroids can decrease one’s eosinophil count below 100.

Do ICS also distort interpretation of one’s blood eosinophil count or is it just oral steroids that do?

This is a great question. My impression has always been that an ICS should not affect the interpretation of patients’ blood eosinophil count because the absorption is low. But if it did, I think it would have a minimal impact. I cannot say that it would have no effect whatsoever, rather, I think it would have a minimal impact.

Do you have any tips for helping patients access the evidence-based inhaler per the GOLD Report when they cannot afford it?

This is a struggle that my office often deals with. Hopefully if patients are not covered by Medicare or Medicaid, they can access their treatment through a prescription discount card or manufacturer-based assistance program. If none of these strategies help, you can put pressure on the insurance company and show them the hard data to establish medical necessity. I did not discuss this above, but there are data too now showing that triple therapy may be appropriate for patients. For example, use of LABA plus LAMA plus ICS has shown to improve patients’ clinical outcomes vs dual therapy. Since these are new data, you may have to make the argument to the insurance company to establish that medical necessity.

In which patients do you prescribe nebulized therapies?

The most important consideration when choosing the route of administration for any medication is to select one that will be able to deliver the medication to the site where it can do its job effectively and safely. When selecting the most appropriate delivery mechanisms for patients with COPD, nebulizers offer an alternative administration route for patients who are unable to effectively use other types of devices, in particular those with cognitive, dexterity, or coordination challenges. Further, nebulizers provide benefit in acute exacerbations. When assessing a patient for optimal device prescriptions, nebulized therapy is always on the list to consider.

Is a recumbent bike as helpful as walking for patients with COPD?

I think it depends on the patient. If they have arthritis or a condition that is going to keep them from walking, then exercising on a recumbent bike is a good idea. It can take pressure off the knees and back, so I think is a great option in those cases. But the bottom line is this: anything that is part of a regular exercise program is going to be helpful for patients with COPD.

Continue

Poll

1.

What characteristics do you consider when assessing if a nebulizer therapy should be added to a patient’s COPD regimen? (Select all that apply)

Submit