New Perspectives on Chronic Obstructive Pulmonary Disease

Abstract

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide; many recent advances have been made in many aspects of the disease. The aim of this article is to illustrate and discuss some of these advances in the management of different types of patients. Large-scale trials have confirmed that long-acting bronchodilator therapy, particularly using the combination of LABA/LAMA, remains the mainstay of COPD treatment, with special attention being paid to careful selection of inhaler devices. The initial choice of pharmacological therapy is based on the GOLD ABCD grouping of patients. It is very important to stress that there is a need to implement a management cycle because COPD is a chronic disease with varying clinical course and a high number of potential comorbidities that may affect morbidity and mortality. Therefore, regular reevaluation of the patient is mandatory. This allows identification of characteristics aimed at maximizing the benefits for a specific patient or a subset of patients. Within this context, the role of the blood eosinophil count as a marker of inhaled corticosteroids response to prevent future exacerbations in patients who, despite appropriate bronchodilator therapy, still suffer from them has been proven to be a useful simple biomarker in medication selection. These advances support the concept of precision medicine, with the goal that patients get the right medicine at the right time for the right reason. Finally, recent studies have shown that early life events may be of critical relevance for the development of COPD. With this as a background, concepts to identify individuals at risk and early identification of cases have become an important objective of current research with the hope of maximizing the effects of therapy and the possibility of impacting disease progression.

Keywords: ABCD grouping; COPD; LABA/LAMA; eosinophil; management cycle.

Figure 1

Distribution of annual declines in FEV1 in four lung-function trajectories, in 2864. Participants in the Framingham Offspring Cohort (FOC) and the Copenhagen City Heart Study (CCHS). A normal FEV1 was ≥80% of the predicted value; low FEV1 <80% of the predicted value. COPD was diagnosed according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) grading system. The mean decline in FEV1 was 24 ml per year in trajectory 1 (FEV1 ≥80% at baseline and no COPD at final examination) (A), 2 ml per year in trajectory 2 (FEV1 <80% at baseline and no COPD at final examination) (B), 53 ml per year in trajectory 3 (FEV1 ≥80% at baseline and COPD at final examination) (C), and 27 ml per year in trajectory 4 (FEV1 <80% at baseline and COPD at final examination) (D). The decline in FEV1 in trajectory 3 was considered to be rapid. From Lange P, Celli B, Agust í A, et al. Lung-Function Trajectories Leading to Chronic Obstructive Pulmonary Disease. N Engl J Med.2015;373:111–122. Copyright© 2015 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

Figure 2

Management of COPD.

Figure 3

Change from baseline in early-morning symptoms after 24 weeks of treatment with the fixed combination of aclidinium bromide/fumarate formoterol, its individual components, and tiotropium. *p≤0.05 vs baseline.