Transcript
Announcer:
Welcome to Clinician’s Roundtable on ReachMD. On this episode, Mr. Brian Bizik joins us to discuss his presentation from the 2026 GOLD International COPD Conference, which focused on how we can determine which additional therapy is most appropriate for a patient who continues to experience exacerbations despite optimized inhaled therapy. Mr. Bizik is a physician assistant and respiratory care coordinator at Terry Reilly Health Centers in Boise and Nampa, Idaho. Let’s hear from him now.
Mr. Bizik:
The big picture with GOLD and all the treatment algorithms is we first need to get an accurate diagnosis. We start the patient on therapy—usually that's a LAMA/LABA—and we advance their therapy. If they have higher eosinophils over 300 or if they're continuing to exacerbate over 100, we're going to consider adding an inhaled corticosteroid, moving them to triple therapy.
At that point, if they're on the right inhaler—either a LAMA/LABA or triple therapy—and they're continuing to exacerbate, we think about what might be contributing to that. This is a great time to ask yourself if they can actuate the inhaler and inhale adequately, and if they're using a spacer holding chamber device, are they using that appropriately? If not, get them one and show them how to do it. And going through those steps can be more important than any medication decision. Are they able to afford the medication, actuate the inhaler, and get it in? If not, I need to change something, add something, or move them to nebulized therapy.
But if I've done that and they're continuing to exacerbate, there are some questions we can ask that might help us understand why they're exacerbating and/or why they're continuing to have shortness of breath. If they're primarily experiencing dyspnea, meaning they can't get that deep and satisfying breath, then we have one pathway. On the other pathway—the exacerbation pathway—ask questions like, is this patient somebody who's just more likely to have flares? Do they have elevated eosinophils? Is that part of their presentation? Because if it is, those cells could be contributing to why they're having more frequent and longer exacerbations. Those patients do poorly. They have more exacerbations. They last longer. Their loss of lung function is accelerated.
So what therapy might be best? If they're on that dyspnea pathway, we have one therapy that GOLD recommends to consider trying, and that's ensifentrine.
If they're on the exacerbation side, meaning they were on the right inhaler, we've advanced therapy, they're using it appropriately, and they're still struggling and coming back in with one, two, or more exacerbations a year or they're hospitalized, then GOLD says, "Hey, you can consider biologic therapy." We have two biologics: dupilumab and mepolizumab. And then we have a PDE4 inhibitor called roflumilast, and you could even consider chronic azithromycin therapy at that time.
If you have a patient with elevated eosinophils and comorbid conditions like asthma or atopic dermatitis, dupilumab makes sense, and it might be the right biologic to consider trying. For those with lower eosinophils—between 150 and 300 or even higher—then we could consider mepolizumab as an option for those patients. Mepolizumab is dosed once a month which is different than dupilumab, which is given every two weeks. So that could be a consideration.
And of course, consider insurance coverage because Medicare or Medicaid may determine which one you choose. And that could be more important than anything because these are costly medicines, so making sure the patient can afford this and we're getting them support for their copays is very important.
Announcer:
That was Mr. Brian Bizik talking about how to select an appropriate therapy for a patient with COPD who’s already on optimized inhaler therapy but still experiences exacerbations. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
