In a recent interview with PharmaShots, Dr. Riju Ray, MD, PhD, Senior Medical Lead at GSK, leading US medical affairs across asthma and COPD shared his views on how community-based pulmonologists are improving COPD management and education among referring PCPs.

Shots:

• Pulmonologists identified 12 strong to moderate predictors of future COPD exacerbations, some of which were evaluated less frequently
• When evaluating COPD traits, pulmonologists were most likely to evaluate behavioral traits, exacerbation history and recovery time rather than traits that require testing, as acknowledged by the standard of care (GOLD guidelines).
• Community-based pulmonologists play an important role in the management of COPD, and the majority of respondents were also in a position to influence COPD management practices of colleagues.

Tuba: Please discuss the epidemiology of the chronic obstructive pulmonary disease (COPD)?

Riju: COPD, or chronic obstructive pulmonary disease, is a progressive lung disease. There are more than 16.4 million people in the U.S. that are diagnosed with COPD, and it is one of the leading causes of death worldwide. While there is no cure for COPD, it is treatable, and with daily management, those with the disease can maintain good quality of life.

Tuba: Can we have a key point of the whitepaper published in Chest Clinical Perspectives in a non-scientific way?

Riju: In the recent study funded by GSK and co-developed by CHEST and GSK, we assessed the approaches pulmonary specialists take when they think of managing COPD exacerbations (or flare-ups) and what clinical perspectives come to mind when they consider future risk of these COPD exacerbations for their patients. These COPD exacerbations, or COPD flare-ups, speed up lung function decline and often lead to hospitalizations, which impact the health and quality of life for people with COPD. Research shows that frequent exacerbations that require hospitalization are also associated with higher mortality. Hospitalizations also lead to greater impact on daily life, decreased ability to work and increased burden on family caregivers, so it is important to help people with COPD reduce their chances of experiencing a COPD exacerbation.

Source: Biophysical Society

Tuba: What were the objectives of the research conducted by CHEST?

Riju: The objectives of the survey were to:

• Assess the frequency with which pulmonary, extrapulmonary, and behavioral traits of COPD patients are evaluated in pulmonology practices.
• Assess which disease characteristics pulmonologists use to predict the occurrence and severity of exacerbations in patients with COPD, including those who have no history of exacerbations.
• Identify barriers to assessing these disease characteristics in pulmonology practices.
• Assess how often pulmonologists are actively involved sharing their knowledge of COPD treatment and management with their referring primary care physicians.

Tuba: Discuss the role of pulmonologists in improving the management of COPD.

Riju: Pulmonologists work with patients to develop a proper COPD management plan and participate in the development of treatment plans. Pulmonologists are also in a position to better educate their referral primary care physicians. According to the survey, COPD is frequently underdiagnosed, which may be partially due to primary care physicians (PCPs) lacking knowledge on the disease. It's important for pulmonologists to utilize their position to educate PCPs on how to administer tests, and interpret results, and plan tailored disease management plans for their patients with COPD.

Tuba:  What were the findings of the research conducted by CHEST/GSK?

Riju: The survey uncovered a few key insights on COPD exacerbation predictors and the role of pulmonologists in better managing future COPD exacerbation risk:

• There are 12 strong disease characteristics that pulmonologists determined to be predictors of a COPD exacerbation.
• Pulmonologists are more likely to evaluate behavioral traits that do not require testing than pulmonary and extrapulmonary factors.
• Most (71%) of pulmonologists surveyed use a strategy-based approach like the GOLD while 29% said their management approach is dependent on a patient’s symptoms.
• The opportunity to educate other physicians on COPD management and exacerbation prevention is not utilized.In fact, only 16% of respondents said they make a routine practice of proactively engaging or informally educating referring physicians on how to evaluate and manage COPD.

Tuba: Can you showcase the GOLD guidelines used by the pulmonologist?

Riju: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy document is used broadly by physicians to guide COPD treatment plans. It categorizes patients according to their level of airflow limitation, symptoms, and comorbidities, and disease stages. However, patients symptom burden and exacerbation history are recommended as 2 key guiding principles for determining optimal treatment. Patients grouped in the same stage of the disease often have variation in symptoms, exacerbations, and risk of mortality, so understanding how to identify and test those characteristics is important to developing a personalized treatment plan.

Tuba: What were the different traits evaluated by the pulmonologist during the research?

Riju: In the survey, pulmonologists evaluated various behavioral, pulmonary and extrapulmonary traits and determined 12 strong COPD exacerbation predictors. The behavioral characteristics include treatment adherence, tobacco use, exacerbation history (especially exacerbations leading to hospitalizations), which do not require testing. Pulmonary and extrapulmonary factors include frailty or airflow limitation, which are evaluated less frequently. This study emphasizes the importance of pulmonologists' recognition of disease characteristics, laboratory testing, in-office assessments and physician education when developing treatment plans. 

• When testing-based characteristics are not routinely evaluated as indicated by surveyed pulmonologists, it creates an overdependence on physician-patient communication. While this study did not specifically address communication, we know that both patients and physicians think there is room for improvement in terms of physician-patient communication during medical appointments. It is an extremely important component of the patient-physician relationship and should be considered in any disease management plan.

Tuba: What are the different predictors of future COPD exacerbations? What you consider is the best predictor for exacerbation?

Riju: The best predictor for an exacerbation is exacerbation(s) history; however, it is important for pulmonologists to evaluate other disease characteristics, especially in the absence of exacerbation history. A focus on behavioral elements like smoking cessation and adhering to their treatments especially controller medicines also ranked high from the surveyed pulmonologists. Regardless of exacerbation history, recent studies suggest triple therapy with an ICS, LAMA, and LABA showed the greatest benefit for improving both lung function and preventing exacerbations.

Tuba: What are the educational benefits of using an approach to COPD management?

Riju: As mentioned, COPD is frequently under-diagnosed, so it is important for pulmonologists to utilize all tools available to them between in-office testing, reference of GOLD and evaluation of a patient's health history when treating people with COPD symptoms. It's also critical pulmonologists engage PCPs in formal or informal education activities to improve patient care from the front line.

Tuba: Why do you think COPD management is necessary to improve the condition of patients?

Riju: Like any disease, proper disease management is essential to ensuring patients receive optimal care and lead a high quality of life as possible. COPD can worsen over time, especially for people who experience frequent exacerbations, but patients don't have to settle for a life of breathlessness. Better days are possible for people living with COPD through consistent and comprehensive disease management.

Image Source: Dimerix Limited

About Author:

Dr. Riju Ray is an MD, PhD senior medical lead within the Respiratory team at GSK US medical affairs leading teams across both Asthma and COPD. He is based out of Research Triangle Park in North Carolina.

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