Examining the Primary Care Physician’s Role in Screening COPD Patients for Alpha-1

Announcer:
You’re listening to Clinician’s Roundtable on ReachMD, and this episode is sponsored by Grifols. Here’s your host, Dr. Jennifer Caudle. 

Dr. Caudle:
Welcome to Clinician’s Roundtable on ReachMD. I’m your host Dr. Jennifer Caudle, and joining me to examine the primary care physician’s role in screening for alpha-1 antitrypsin deficiency in patients with chronic obstructive pulmonary disease, or COPD for short, is Dr. Brian Smith, who’s in private practice at Versailles Family Medicine in Kentucky. Dr. Smith, thanks so much for being here today.

Dr. Smith:
Happy to join you.

Dr. Caudle:
So let’s just dive right in, Dr. Smith. Can you tell us about the role primary care physicians have in screening for alpha-1 in patients with COPD?

Dr. Smith:
Yes, well as you know with most diseases, primary care clinicians are the first people that patients will come to with a complaint, and COPD is no different. I think we take care of the vast majority of COPD patients without ever consulting with other colleagues. One of the things that can cause COPD is alpha-1, and so in the primary care practice, screening for alpha-1 is often the only place a patient might have the opportunity to be tested for that disease state.

Dr. Caudle:
And what kind of impact do you think early detection will have on our patients?

Dr. Smith:
Well there have been a few studies that talk about patients after they’ve been diagnosed with alpha-1 and smoking quit rates after diagnosis and education and counseling. And they are more likely to quit smoking than COPD patients without alpha-1. And then there’s also a few therapeutics available that if you start for alpha-1 early, they’re more effective. And then I think from a primary care standpoint, it raises our awareness that this patient is not a standard COPD patient and possibly to treat them more aggressively or be more aware that they’re having frequent exacerbations or coming to the office more often, that type of thing.

I think one final impact for the early detection of alpha-1 is family awareness. Since it is a genetic disease, often what we discover is when we test one patient and they’re positive, we find several of the family members that end up being positive also, and so there’s clusters of this disease in many communities. So that is another impact of screening for patients for alpha-1.

Dr. Caudle:
And with that background in mind, Dr. Smith, let’s zero in on key screening strategies. First, which of our patients should we be screening based on the latest clinical guidelines?

Dr. Smith:
Really, to keep it simple, the way I do it – and this is very consistent with the clinical guidelines – is any patient with COPD who has irreversible defects. It becomes tricky because a lot of primary care, as you know, don’t have access to spirometry, so we can’t test for that irreversibility very easily. We know COPD patients when we see them, and if we can get spirometry, that’s helpful, but really we should be screening any patient that comes to our office with COPD. So the way I kind of teach students is if you’re prescribing an inhaler, then you should be testing that patient for alpha-1.

Dr. Caudle:
And then, how exactly can we screen COPD patients for alpha-1? Can you walk us through that process?

Dr. Smith:
There’s two simple ways to do it. Alpha-1 is genetic disease, so we need to get some DNA and so we can do that with either a finger stick, just like testing somebody’s glucose. We can draw their blood, and then draw a little bit of blood out of the tube. You know, we’re sending it off for a CBC. Or we can also do a saliva test, and then send that off for DNA analysis. There are a number of commercial labs that have that test availability, and then most of the companies that make the therapeutics for alpha-1 will also offer that testing for free in patients in our office practices.

Dr. Caudle:
For those of you who are just tuning in, you’re listening to Clinician’s Roundtable on ReachMD. I’m your host Dr. Jennifer Caudle, and I’m speaking with Dr. Brian Smith about the primary care physician’s role in screening COPD patients for alpha-1 antitrypsin deficiency.

So Dr. Smith, we spoke earlier about the importance of screening patients for alpha-1, but what are some diagnostic challenges primary care physicians should be aware of?

Dr. Smith:
Like I said before, I think spirometry availability in primary care is a big challenge. We’re supposed to use spirometry to officially diagnose COPD, but the availability, either due to cost or integration with EMRs or whatever, is I think it’s something like 20% or fewer primary care practices have spirometry in their office. And then I think sometimes the interpretation of the alpha-1 test can be a little bit tricky because there’s multiple different results that can be positive or negative, but then there’s also some gray area where the diagnosis may be in question based on the patient’s presentation.

Dr. Caudle:
And can you share some best practices for overcoming these challenges?

Dr. Smith:
Well for us, we actually have spirometry in our practice, so that is very helpful. But if a practice does not have spirometry, I think the kind of rule of thumb, and it’s a little bit overkill, but it’s not far outside the guidelines – is if you’re prescribing any kind of inhaler to a patient, then testing them for alpha-1 is a reasonable thing to do. Like I said earlier, there’s free testing available from multiple companies, and so the patient isn’t out any money, you know, going to their insurance or anything like that for the test. It’s a very nice solution if patients have concerns about cost or the insurance finding out that they have the genetic disease or something like that.

Dr. Caudle:
We’ve covered a lot of ground today, Dr. Smith, but before we close, do you have any final thoughts you’d like to leave with our listeners?

Dr. Smith:
I would say we treat in primary care the vast majority of COPD patients, and so if we are not testing them for alpha-1, then they can’t advise their family members. They can’t take into consideration a stronger incentive to stop smoking, take better care of themselves, maybe even job alterations. Here in Kentucky, we still have some coal miners, and that kind of stuff can also irritate your lungs and cause COPD. So I think testing in the primary care field for alpha-1 is critical to get the vast majority of patients.

Dr. Caudle:
Well as those final thoughts bring us to the end of today’s program, I’d like to thank my guest, Dr. Brian Smith, for joining me to discuss the primary care physician’s role in screening patients with COPD for alpha-1 antitrypsin deficiency. Dr. Smith, it was great having you on the program.

Dr. Smith:
You’re more than welcome, and it’s wonderful talking to you and sharing some information about alpha-1.

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