Louis Roller takes a look at COPD and practice points for pharmacists

“When you can’t breathe … nothing else matters”

COPD is characterised by airflow limitation that is not fully reversible with the use of medication. 

People with COPD may also have a persistent cough with sputum due to excessive mucus production in the airways (chronic bronchitis) or evidence of lung tissue destruction, enlargement of the air sacs and further impaired lung function (emphysema).

In 2011, COPD was the fourth leading specific cause of total burden. The terms COPD, emphysema and chronic bronchitis are often used interchangeably. 

COPD may be associated with other chronic conditions such as asthma, respiratory cancers, diabetes and diseases of the heart and blood vessels due to shared risk factors and the effect of COPD on other parts of the body.

The main cause of COPD is active smoking or exposure to smoking, however other causes may be involved, such as:

  • smoke from burning fuels of plant or animal origin;
  • outdoor air pollution;
  • fumes and dust in the workplace;
  • childhood respiratory infections; and/or
  • chronic asthma.

It can be difficult to distinguish COPD from asthma because the symptoms of both conditions can be similar. Although the current definitions of asthma and COPD overlap, there are some important features that distinguish typical COPD from typical asthma.

For example, people with COPD continue to lose lung function despite taking medication, which is not a common feature of asthma.  

There is increasing recognition of asthma-COPD overlap (also called Asthma-COPD Overlap Syndrome, or ACOS), which affects around 15–20% of people with either diagnosis.

It is important to identify people with asthma-COPD overlap, because they are at higher risk than patients with asthma or COPD alone, and because they should be treated differently from people with asthma or COPD alone].

The development of COPD occurs over many years and therefore affects mainly middle aged and older people while asthma affects people of all ages.

The prevalence of COPD increases with age, mostly occurring in people aged 45 and over. COPD ranked in the top three causes of total burden for those aged 65─74 and 75─84, and was the second highest ranked cause of total burden for men aged 75─84.

The prevalence of COPD is difficult to determine from routine health surveys.

Since COPD is formally defined in terms of an abnormality of lung function, accurately estimating the prevalence of the disease requires clinical testing.

In the 2014–15 ABS National Health Survey (NHS), the prevalence of COPD in Australians aged 45 and over was 5.1%, an estimated 460,400 people. The prevalence did not differ significantly between males and females (5.2% and 4.9% respectively).

COPD affects an estimated 8.8% of Indigenous Australians aged 45 and over—approximately 10,300 people, based on self-reported data, although this is likely to be an underestimate. The prevalence of COPD (across all age groups) among Indigenous Australians is 2.5 times as high as the prevalence for non-Indigenous Australians after adjusting for differences in age structure.

COPD affects quality of life:

  • COPD can interrupt daily activity, sleep patterns and the ability to exercise.
  • People with COPD rate their health worse than people without the condition. In 2014–15, 22% of those aged 45 years and over with COPD rated their health as poor, compared to 6% of those aged 45 years and over without it.
  • Comorbidities People with COPD often have other chronic diseases and long term chronic conditions.

Pharmacists should be familiar with the  large number of medications (inhaled) used in the treatment of COPD:

  1. Short-acting reliever medications bronchodilators (SABAs) short-acting beta2 agonists (salbutamol, terbutaline) or a short-acting antimusacarinic (SABAs)

            (ipratropium)

  1. Symptom relief medications- Long acting muscarinic agents (LAMAs): acidinium bromide, glycopyrronium bromide, tiotropium, umeclimidium

            Long acting beta-agonist (LABA) agents: indacaterol, salmeterol

            LABA/LAMA combinations: indacaterol/glycopyrronium, umeclidinium/vilanterol

  1. Exacerbation prevention: inhaled corticosteroid and long-acting beta-agonist: budesonide/formoterol, fluticasone valerate/vilanterol

The COPD-X Plan: The adoption of the Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease, 2018 Latest version) Guidelines is vital for pharmacists and they should encourage their COPD patients to follow the recommendations.

The key recommendations are summarised in the “COPDX Plan”: – ie

            C- Confirm diagnosis and assess severity

            O- Optimise function

            P- Prevent deterioration

            D- Develop support network and self-management plan

            X- manage eXacerbations.

The guidelines aim to:

  • effect changes in clinical practice based on sound evidence; and
  • shift the emphasis from a predominant reliance on pharmacological treatment of COPD to a range of interventions which include patient education, self-management of exacerbations and pulmonary rehabilitation.

 The long term goals of the COPD Strategy are the: 

  • primary prevention of smoking
  • improving rates of smoking cessation
  • early detection of airflow limitation in smokers before disablement and improved management of stable

Practice points for pharmacists

  • check inhaler technique and compliance regularly
  • minimise use of different devices by using fixed-dose combination inhalerswhere possible, according to patient preference; when starting combination inhalers, stop all inhalers containing drugs from the same class
  • in stable disease, administering bronchodilators via an MDI or DPI is preferred to nebulisation; consider use of a spacer with MDIs, particularly for patients with poor inspiratory effort, or impaired coordination and/or dexterity
  • during an exacerbation, nebulisers or inhalers with spacers may be used to administer bronchodilators
  • consider developing a written action plan for management of exacerbations.

www.lungfoundation.com.au/​health-professionals/​clinical-resources/​copd/​copd-action-plan/​

Associate Professor Louis Roller, from the Faculty of Pharmacy and Pharmaceutical Sciences Monash University, was the 2014 recipient of the PSA Lifetime Achievement Award.