Future Management of COPD Sees Shift in Approach to Treatment

Chronic obstructive pulmonary disease (COPD) is a leading cause of disability and mortality and is significant strain on the healthcare industry, creating personal and financial burdens that must be addressed. However, according to a recent article published in the International Journal of Chronic Obstructive Pulmonary Disease, evolving scientific evidence on the natural history and clinical course of COPD has fueled a fundamental shift in how clinicians treat the disease.

The article, written by Richard Russell, Antonio Anzueto and Idelle Weisman, states that “the goals of therapy for COPD are no longer confined to controlling symptoms, reducing exacerbations, and maintaining quality of life.” Slowing disease progression is now the main goal of therapy and is becoming an achievable aim.

This shift is a result of multiple findings, including the emergence of data highlighting the heterogeneity in rate of lung function decline, which has altered perceptions of disease progression and understanding of strategies for the management of stable disease.

“A challenge for the future will be to capitalize on these observations by improving the identification and diagnosis of patients with COPD early in the course of their disease, so that effective interventions can be introduced before the more advanced, disabling and costly stages of the disease,” researchers add.

Further, researchers examine the latest understanding of COPD to evaluate the current and potential approaches to long-term treatment. This includes treatments such as early, effective, and prolonged bronchodilation to slow the decline in lung function and reduce the frequency of exacerbations.

Click Here to Access the Full Article from Dovepress

LVRS Surgery

hLung Volume Reduction Surgery Proven Beneficial to Emphysema Patients

Lung volume reduction surgery (LVRS) may improve the quality of life and overall well-being in patients with severe emphysema, according to the National Emphysema Treatment Trial (NETT), the first study to randomize emphysema patients to receive LVRS or non-surgical medical care.

Researchers for NETT recruited 1,218 patients with severe emphysema and randomized them to either undergo LVRS or non-surgical medical treatment which consisted of customized use of medication, oxygen support, smoking cessation and pulmonary rehabilitation. Of the sampled population, 608 patients underwent LVRS and 610 received standard medical care. They were monitored for five years, or until a “composite event” (a serious decline in quality of life or death) occurred. The average time until such an event was one year for medically treated patients and two years for patients who underwent LVRS.

“We found lung reduction surgery is good treatment alternative for selected emphysema patients since it not only improves survival but also meaningfully improves quality of life for a period of at least five years after the operation,” said lead author of the study, Roberto Benzo, M.D., MSc., Mayo Clinic. “Patients who underwent LVRS, with the exception of those who had non-upper-lobe-predominant emphysema, had both a survival and quality of life benefit when compared to similar patients undergoing medical treatment only.”

For patients who received LVRS, a portion of the emphysematous lung tissue was removed to prevent “air-trapping,” where the patient can inhale but is unable to force the air back out of the lung.

“By removing the section of lung that is primarily affected with severe emphysema, we can decrease air trapping and consequently the shortness of breath, which can thereby improve the patient's perceived quality of life,” said Dr. Benzo.

Researchers caution that LVRS carries serious risks. In the study, nearly 5% of the patients who underwent LVRS died following surgery. However, once the post-operative period is over, the patients’ quality of life is improved immediately. Full Story

Gene Therapy May Prevent the Progression of Emphysema

Researchers from Boston University School of Medicine (BUSM) have discovered a new gene therapy that may prevent the progression of emphysema. The study, published online in the Journal of Clinical Investigation, describes a method of treatment that will express therapeutic genes in lung tissues over a lifetime after a single treatment.

The genetic mutation of Alpha-1 Anti-trypsinis, and subsequent deficiency, is the most commonly inherited form of emphysema seen in young people. It predisposes affected individuals to early emphysema and cirrhosis of the liver.

According to researchers, gene transfer into specific cell lineages in vivo remains an attractive yet elusive approach for correcting inherited mutations and preventing subsequent diseases such as emphysema.  In vivo gene transfer has been limited in many types of cells by inefficient gene delivery, as well as the limited life-span of differentiated cell types.

However, using mice, the BUSM researchers have discovered a way to deliver genes selectively to as many as 70 percent of a mouse lung’s alveolar macrophages (AM), a key cell type contributing to emphysema. Researchers applied this approach to achieve sustained in vivo expression of normal human alpha-1 antitrypsin (hAAT) protein levels capable of improving emphysema in mice. As a result, the lung macrophages carrying the therapeutic gene survived in the lung for a two-year lifetime following a single intra-tracheal injection of the engineered lentiviral vector.

"The progression of emphysema in mice exposed to elastase was significantly improved by the gene therapy as evidenced by improvements in lung compliance and alveolar size," said Dr. Andrew Wilson, lead author of the study and assistant professor of medicine at BUSM.

After 24 weeks of sustained gene expression, no humoral or cellular immune responses to the human hAAT protein were detected in the mice, challenging the idea that lung macrophages are short-lived and suggesting that these differentiated cells may be considered for in vivo gene therapy applications such as the sustained correction of hAAT deficiency. Click here to access the full story on ScienceDaily.

Gene Variant said to Protect against Asthma, COPD

A variant of the gene MMP12, which plays a role in inflammation, seems to protect the lungs of children with asthma and adults who smoke, according a recent study. This new gene raises hope that improved prevention and treatment of chronic obstructive pulmonary disease (COPD) will be discovered.

Researchers have found that levels of the MMP12 gene may impact the quality of life for those individuals who suffer from asthma and COPD. They also found that adult smokers with this variant of the gene have a lower risk of developing COPD, a condition often brought on by smoking.

Linked to the development of emphysema in mice exposed to smoke, the gene is thought to be important in the onset of emphysema in humans. It can also be linked with other genes involved in asthma. This information, combined with the fact that factors that can cause the onset of asthma in children are also involved with how well your lungs function in adulthood, is what spurred investigators to being this study.

Dr. Juan C. Celedon, associate professor of medicine at Brigham and Women’s Hospital and Harvard Medical School, and his colleagues studied seven different groups of people, in all 8,300 children and adults. Their findings, published in the New England Journal of Medicine, shed light on the association the variant of MMP12 has to better lung function in children with asthma, adult smokers, and the connection between asthma and COPD.

"There is certainly overlapping in that how you get asthma and how you get COPD is related and probably very closely related," said Jeffrey Cirillo, professor of microbial and molecular pathogenesis at Texas A&M Health Science Center College of Medicine in College Station."That's exciting because it suggests that if we can decrease or increase expression of genes that are common to both, we could potentially affect both. It's nice to have one treatment."

By understanding more about MMP12, researchers are hopeful that they will be able to come up with new therapeutic approaches including ways to induce or oppress the protein expression in the lungs and treat COPD and asthma.  Click here to read the full story on MedicineNet.

Even Mild COPD May Limit Heart Function

Researchers have long known that severe cases of chronic obstructive pulmonary disease (COPD) have diminished the heart’s ability to pump blood effectively. However, a new study funded by the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health suggests that there are strong links between heart function and mild COPD.

The study, published in the Jan. 21 issue of the New England Journal of Medicine, is the first research to show that COPD diminishes the heart’s ability to pump effectively even when the disease has mild or no symptoms. This suggests that the changes in the heart occur much earlier than previously believed – even before symptoms appear.

Researchers measured the heart and lung structure and function in 2,816 generally healthy adults who were part of the Multi-Ethnic Study of Atherosclerosis (MESA) Lung Study, an extension of a large, NHLBI-supported study focused on finding early signs of heart, lung and blood diseases before symptoms appear.

Using sensitive magnetic resonance imaging (MRI) and computed tomography (CT) scans, researchers uncovered mild abnormalities in heart and lung function in many participants with the link between the two strongest in current smokers who are at risk for both diseases, especially those with emphysema. The findings also appeared, to a lesser extent, in people with mild COPD who had never smoked.

"These results raise the intriguing possibility that treating lung disease may, in the future, improve heart function," said Graham Barr, M.D., Dr. P.H., assistant professor of medicine and epidemiology at Columbia University Medical Center in New York City, principal investigator of the MESA Lung Study, and lead author of the paper. "Further research is needed to prove whether treating mild COPD will help the heart work better." Click here to access the full story on NIH News

Asthma, Emphysema Patients May Be Misusing Inhalers

Many people with asthma or emphysema may be taking their inhaled medications incorrectly, according to a recent study published in the Journal of General Internal Medicine.

The study, which observed 100 adults hospitalized for asthma or other lung diseases while using their inhalers, found that patients misused metered-dose inhalers nine out of 10 times and Diskus inhalers seven out of 10 times. The patients included in the study were admitted to one of two hospitals in the Chicago area because of serious asthma or a worsening of their COPD, with some patients hospitalized due to near-fatal complications.

For people who use both metered-dose and Diskus inhalers, which researchers note is quite common, learning to use both types of inhalers can be tricky. That is because while both inhalers deliver medication to the lungs, they work by different mechanisms and require different steps to deliver medication. Used mainly as a controller medication, Diskus inhalers require a sharp inhalation for maximum effectiveness. Conversely, metered-dose inhalers, which can be used as both controller and rescue medication, must be inhaled slowly.

Researchers note that one of the biggest problems found in the use of inhalers was that patients failed to breathe out fully before placing the inhaler in their mouth. Another obstacle appeared to be vision problems, which researchers believe may impact patients’ ability to read the inhaler’s instructions and properly use them.

On a positive note, researchers found that it did not take much instruction to improve people’s inhaler use. Of the 100 study participants, 42 were given one or two lessons on how to use the devices and all were able to master the techniques for both inhalers.

For people with asthma or COPD, trouble controlling symptoms may be a sign that the inhaler isn’t being used correctly. That is why it is important for people using inhalers for lung disease treatment to bring them to their doctors’ appointments and demonstrate how they use the devices at home. Doctors will then be able to correct poor practices and ensure that patients are receiving the correct dose of medication to their lungs.

Click Here to Access the Full Story From the Journal of General Internal Medicine

Study Challenges Provisions for End-of-Life Care in COPD Patients

A recent study published in the British Medical Journal has challenged the current assumptions supporting the provisions for end-of-life care for people with chronic obstructive pulmonary disease (COPD).

The study, titled “Living and Dying with Severe Chronic Obstructive Pulmonary Disease,” was developed to better understand the perspective of people with COPD as their illness progresses, as well as the perspectives of their professional and informal caretakers. Conducted through a number of qualitative interviews over an 18-month period, the study examined 21 patients, 13 informal caretakers (family members, friends, neighbors) and 18 professional caretakers nominated by the patients. During the study period, 11 patients died.

Through the interview process, researchers revealed that severe symptoms that caused major disruptions to normal life were often described as a “way of life” rather than an illness, and overall patients told a “chaos narrative” of their illness that was indistinguishable from their life story. Attitudes toward death were described as normal in an elderly population.

“People with very severe COPD have a well recognized burden of disabling physical symptoms (especially breathlessness), compounded by comorbidity, psychological distress, and social isolation,” wrote researchers. However, the chaos narrative has made it difficult for caretakers to define a point where palliative care might be appropriate.

Further, researchers believe that the policy focus on identifying a time to transition to palliative care has little resonance with patients based on the accounts described during the study. It may also be counterproductive if it distracts professional caretakers from timely consideration of providing much needed supportive care.

Click Here to Access the Full Study from Medscape

The National Association of Managed Care Physicians (NAMCP) Unveils COPD Resource Center

The National Association of Managed Care Physicians (NAMCP) has unveiled the Medical Directors COPD Resource Center, a resource designed to provide medical directors, practicing physicians and patients with up-to-date information on the diagnosis and treatment of chronic obstructive pulmonary disease (COPD).

The resource center was designed by a team of medical directors from various purchasers, plans and providers who saw a need for an unbiased information source on the various techniques currently used to help improve patient outcomes in the COPD patient population.

“We needed one spot to research new information on the diagnosis and treatment of COPD. The web-based Medical Directors COPD Resource Center is that place,” said Ron Hunt, MD, Medical Director of Blue Cross Blue Shield of Georgia, who was a member of the COPD Resource Center Advisory Board, in a statement released by the NAMCP.

The end result features a number of tools that can assist both physicians and patients in managing the disease. For example, the NAMCP COPD Physician Audit Tool, which is available in the resource center, can help physicians monitor the progress of their patients over the course of their treatment.

Further, the NAMCP COPD Patient Health Record can assist patients in determining if they have the signs and symptoms often associated with COPD. Once completed, this resource can be utilized during doctor appointments, where the physician and patient can review the results together.

The Medical Directors COPD Resource Center is the latest in a series of resource centers released by NAMCP. Other resource centers include bipolar disorder, diabetes, weight management and sleep disorders. For more information on these resources, visit www.namcp.org.

Click Here to Access the NAMCP COPD Resource Center

COPD Comorbidities Linked to Higher Risk for Death

A number of comorbidities commonly associated with chronic obstructive pulmonary disease (COPD) are independently associated with a higher likelihood of death. That is according to “Comorbidities and Risk of Mortality in Patients with COPD,” a study published in the American Journal of Respiratory and Critical Care Medicine on May 3.

A key cause of morbidity and mortality, COPD is commonly accompanied by comorbidities such as cardiovascular and cerebrovascular disease, cancer and diabetes. However, little research has been completed on the prognostic value of capturing the effects of these comorbidities in patients with COPD.

As part of the study, researchers followed 1,664 patients with COPD for a median of 51 months. During that time, 79 comorbidities were recorded. Mortality risk was then calculated and a COPD comorbidity index (COTE) was constructed based on the comorbidities that increase mortality risk using a multivariate analysis.

Of these comorbidities, 12 were associated with increased risk of death. These include cancers of the lung, pancreas, esophagus and breast, followed by pulmonary fibrosis, atrial fibrillation/flutter, congestive heart failure, coronary artery disease, gastric/duodenal ulcers, liver cirrhosis, diabetes with neuropathy and anxiety.

“These easily identifiable comorbidities could be screened by healthcare providers caring for COPD patients, as there may be effective interventions that may help decrease the risk of death,” said lead author Miguel Divo, MD, a physician in the Pulmonary and Critical Division at Brigham and Women’s Hospital and an instructor in medicine at Harvard Medical School, Boston, said in an American Thoracic Society news release.

Authors note that these findings raise the possibility of a close interaction among these diseases that may share common biological pathways.

Click Here to Access the Full Study From the American Journal of Respiratory and Critical Care Medicine.