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Dr. Bhatt:
This is CME on ReachMD, and I'm Dr. Surya Bhatt. Here with me today is Dr. Meilan Han. Let's talk management, Dr. Han. As clinicians, what should we be aiming for in the treatment of patients with COPD?
Dr. Han:
That's a great question, Surya. So I really think we need to focus on personalized management plans for our patients, thinking about their phenotype and the type of inflammation that they have, as well as the symptoms that we're trying to target, whether that's shortness of breath, exacerbations or both. One thing that GOLD is really emphasizing is, first, getting the patient appropriately characterized if they are not on anything. And so that's the ABE stratification, which relates to both symptoms as well as exacerbation risk. And then it's also reducing risk in any way we can through things like smoking cessation, vaccinations. And then every time the patient comes in, really kind of, again, doing a systematic review of symptoms, exacerbation, shortness of breath, assessing the medications they're on, tweaking if needed, changing if needed, and then bringing the patient back, and just kind of continuing to do that.
One of the things that we are realizing now in terms of patient-specific phenotypes, is the importance of type 2 inflammation. So I think having an eosinophil characterization as a biomarker for type 2 inflammation is also becoming increasingly important.
Dr. Bhatt:
Thank you, Dr. Han. In an earlier video, we talked about a patient at initial diagnosis and how we start treatment for a patient with certain characteristics. When they come back to see us again, we have to make some decisions about whether they're doing well, and if not we need to make some adjustments to their treatment. Can you take us through a case of a patient who needs some adjustments to treatment?
Dr. Han:
Yes, this is something I get asked about a lot. So let's think about a 59-year-old woman with a 5-year history of COPD, former smoker of 35-pack-years, who's on triple therapy with LABA/LAMA and ICS, but she's still got a productive cough, wheezing. She had two exacerbations in the last year, one of which required hospitalization. Her FEV1 is around 65% predicted. She's got 375 blood eosinophils and a FeNO level of 35. You’ve gotten her to stop smoking. She's got all of her vaccinations. She's using her inhaler correctly. The real question is, what more can be done?
So if we go to the GOLD treatment strategy for a patient on triple therapy, where can we go from here? Well, one option might be roflumilast. This has been shown to be most beneficial in patients with a history of chronic bronchitis, which this patient has, but really more in the patients with more severe lung function abnormality, so FEV1 less than 50%. So maybe not the best candidate for roflumilast. Azithromycin is an option and is something that could be tried. Clinically, I would do things like maybe get a CT, make sure she has no concerns for nontuberculous mycobacteria, make sure her hearing is good, check an EKG. There's a lot of things from a safety profile you really have to think about with the use of azithromycin.
So that's really kind of if we look at the current GOLD framework, some things that could be done for this patient.
Dr. Bhatt:
Thank you, Dr. Han. You mentioned high blood eosinophils, high FeNO, so it sounds like this patient has some characteristics of type 2 inflammation. Given that no type 2 inflammation-targeted agent is approved yet for COPD, there's no placement in the guidelines for these therapies as of now. How do you suspect these agents may fit in the future?
Dr. Han:
Right. Well, if you listen to the other episodes, you'll know that there's a lot of biologics currently under investigation for COPD, many of which target type 2 inflammation. I think with the elevated eosinophils and FeNO, for this patient, she really is displaying an element of type 2 inflammation. So once you know, assuming we get approval for targeted biologics, I think she would be an excellent candidate for one of those.
Dr. Bhatt:
Thank you. I think it's important to remember that the goals of COPD treatment are twofold; one is to manage symptoms and one is to reduce the risk of exacerbations. And this is reflected by the ABE paradigm in the GOLD document. And individualized treatment is very essential to optimize COPD management. And it's very important to periodically review how a patient is doing and ask them the pertinent questions about symptoms and exacerbations, adjust treatment as needed, and then keep repeating this to get the most optimal care for our patients. And it's important to incorporate biomarkers in our treatment uh algorithms, as they're increasingly proving to be uh helpful for identifying the right patient for the right treatment.
Well, this has been a great micro-discussion. Unfortunately, our time is up. Thank you for listening.
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