Desktop Helper No. 10 - Rational use of inhaled medications for the patient with COPD and multiple comorbid conditions: Guidance for primary care - online
This is an online version of Desktop Helper No. 10 - Rational use of inhaled medications for the patient with COPD and multiple comorbid conditions: Guidance for primary care. Visit the linked page for a PDF, translations, more information and related resources. References are available at the bottom of this page.
This desktop helper describes the challenges associated with the pharmacological management of the patient with COPD and multiple comorbid conditions with a particular focus on the rational use of inhaled corticosteroids and provides guidance for the holistic care of such patients in the primary care setting.
Introduction
Chronic obstructive pulmonary disease (COPD) is typically accompanied by multiple comorbid conditions. However, guidelines for the management of patients with COPD focus on the disease itself, providing little practical guidance on the routine management of comorbidities. Our objective is to review the impact of comorbidities on treatment choices for patients with COPD, especially with regard to the risks and benefits of inhaled medications including long-acting beta-agonists (LABA) and long-acting muscarinic antagonist (LAMA) and with a special focus on inhaled corticosteroids (ICS).
Multimorbidity in COPD
Patients with COPD typically present with multiple comorbid conditions which require long-term management alongside their COPD.1 An additional challenge is that concomitant conditions, such as asthma or bronchiectasis, can be overlooked because signs and symptoms may overlap with those associated with COPD. Over 85% of adult patients with COPD will have at least one comorbid condition of clinical relevance, half of them have three or more. (1,2) The prevalence of comorbidities increases with worsening COPD severity in both men and women and women appear to have a greater susceptibility to asthma, osteoporosis, anxiety and depression but appear less likely to have cardiovascular disease than men. (2-4)
Comorbidities often appear in clusters which suggests common risk factors (smoking and inactivity are risk factors for both COPD and lung cancer), shared underlying pathobiological mechanisms (accelerated ageing is associated with both COPD and hypertension) and side effects of COPD treatment (development of diabetes). (5-7)
Managing the patient with COPD
Managing the multimorbid patient with COPD
The management of individual patients with COPD and multimorbidity is often complex requiring the simultaneous application of several disease-specific treatment guidelines. These guidelines are rarely aligned with regard to treatment recommendations (9) therefore a holistic approach is of particular importance for patients with multimorbidity. We would encourage primary care physicians to undertake regular (at least annual) (re)assessment and treatment adjustment for patients with COPD. Emergence of multimorbidity should be regarded as a signal and call to action to undertake a review of COPD treatment with a focus on the interface between symptoms of their comorbid diseases, treatment adherence and side effects of medication.
For patients with COPD, multimorbidity is associated with a high level of polypharmacy and an increased risk for adverse drug reactions and interactions as well as an increased risk of hospitalisation and premature death. (1,5,10-14) Polypharmacology is of particular concern when drugs with potential for similar adverse reactions are combined. (15)
In general, multimorbidity should not delay or alter the treatment of COPD and comorbidities should be managed according to usual standards; attention should be directed to ensure treatment simplicity and to minimise polypharmacy. (8)
Comorbidities of special interest
The management of patients with COPD and multimorbid conditions requires a personalised approach. Primary care physicians should adopt systematic ways to monitor patients with COPD. Τhe interface between symptoms of comorbid diseases and side effects of medication should also be considered with special attention paid to the following comorbidities:
- Asthma
- Osteoporosis/fractures
- Diabetes
- Pneumonia and tuberculosis
- Atrial fibrillation
- Chronic pain
- Chronic kidney disease
- Prostate disease
- Gastroesophageal reflux
- Anxiety and/or depression
- Obstructive sleep apnoea
General action points to improve the managament of the multimorbid patient with COPD in the primary care setting
Optimise the treatment regimen according to local and, ideally, GOLD guidelines (8) and assess and treat comorbidities. When initiating patients on bronchodilator therapy, evaluate the risk for atrial fibrillation (LABA) and the risk for exacerbating urinary symptoms among patients with comorbid renal or prostate disease (LAMA). In addition, think carefully about the indications for ICS use before prescribing. Use in line with guideline recommendations and note the latest IPCRG advice on appropriate use of ICS and guidance on ICS withdrawal. (16)
Additional essential action points
- Increase awareness of COPD multimorbidity and screen and monitor patients for the most common comorbidities
- Ensure at least yearly patient (re)assessment and treatment adjustment in the primary care setting, including stopping of inappropriate medication. Don’t forget lung cancer.
- Review inhalation technique and adherence to medication
- Empower multimorbid patients with COPD and caregivers to help them cope with potentially overwhelming amounts of information and associated depression and anxiety
- Carefully evaluate the indication before initiating ICS treatment. With regard to ongoing ICS treatment, consider
- Asthma: ICS treatment must be continued
- Diabetes: reconsider if ICS treatment is needed; if ICS is continued, close follow up, glucose monitoring and titration of antidiabetic treatment are required
- Osteoporosis: reconsider if ICS treatment is needed; if ICS is continued, close follow up for loss of bone mineral density and risk of fractures is required. Screening for osteopenia or osteoporosis is recommended in patients receiving high dose of ICS or low to medium dose ICS with frequent use of oral corticosteroids
- Infections (pneumonia or tuberculosis): consider withdrawal of ICS and maximize bronchodilation
- Closely monitor for cardiac rhythm disorders, including atrial fibrillation, when initiating patients on a LABA
- Monitor for emergent urinary symptoms when initiating patients with chronic kidney or prostate disease on LAMA
Treatment considerations for the multimorbid patient with COPD
References
- Chetty U, et al. Chronic obstructive pulmonary disease and comorbidities: a large cross-sectional study in primary care. Br J Gen Pract 2017;67:e321-8
- Dal Negro RQ, et al. Prevalence of different comorbidities in COPD patients by gender and GOLD stage. Multidisciplin Respir Med 2015;10:24
- Barr RG, et al. Comorbidities, patients knowledge, and disease management in a national sample of patients with COPD. Am J Med 2009;122:348-55
- Jenkins CR, et al. Improving the management of COPD in women. Chest 2017;151:686-96.
- Divo MJ, et al. COPD comorbidities network. Eur Respir J 2015;46:640
- Decramer M, et al. Chronic obstructive pulmonary disease. Lancet 2012;379:1341-51
- Barnes PJ. Senescence in COPD and its comorbidities. Ann Rev Physiol 2017;79:517-39.
- Global Initiative for Chronic Obstructive Lung Disease (GOLD). 2020 Global Strategy for Prevention, Diagnosis and Management of COPD. Available at: https:// goldcopd.org/gold-reports/
- Dumbreck S, et al. Drug-disease and drug-drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines. BMJ 2015;350:h949
- Tsiligianni IG, et al. Managing comorbidity in COPD: a difficult task. Current Drug Targets 2013;14:158-76
- Lozano R, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2095-218
- Quaderi SA, Hurst JR. The unmet global burden of COPD. Global Health Epidemiol Gen 2018;3:e4
- Mounce LTA, et al. Predicting incident multimorbidity. Ann Fam Med 2018;16:322-9
- Morrison D, et al. Managing multimorbidity in primary care in patients with chronic respiratory conditions. npj Prim Care Respir Med 2016;26:16043
- Martinez CH, et al. Defining COPD-related comorbidities 2004-2014. Chron Obstruct Pulm Dis 2014;1:51-63
- IPCRG. Desktop helper 6: Evaluation of appropriateness of inhaled corticosteroid (ICS) therapy in COPD and guidance on ICS withdrawal. Accessed December 2019
Additional information
Authors: Ioanna Tsiligianni, Kristian Hoines, Christian Jensen, JanWillem WH Kocks, Bjorn Stallberg, Claudia Vicente, Rudi Peche
Reviewers: Stewart Mercer, Luîs Andres Amorim Alves
Editor: Tracey Lonergan
Boehringer Ingelheim provided an unrestricted educational grant to support the development, typesetting, printing and associated costs but did not contribute to the content of this document.
This desktop helper is advisory; it is intended for general use and should not be regarded as applicable to a specific case.
Creative Commons Licence Attribution-NonCommercial-NoDerivatives.
The IPCRG is a Scottish-registered charity (No. 035056) and a Scottish company limited by guarantee (Company No. SC256268).
Communication address: 19 Armour Mews, Larbert, FK5 4FF, Scotland, United Kingdom.
Resource information
- COPD
- Multi-morbidity
- Inhalers
- Treatment - drug
- COPD Right Care
- COPD
- Diagnosis
- Management
- Review
- Risk Factors
- When control is poor
- Clinical Education