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These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
For decades, COPD management has focused on reducing symptoms and slowing decline. However, many patients still experience repeated exacerbations despite optimal treatment—but things are changing.
Dr Clare Tiedeman, a respiratory physician and clinical lead of the Advanced Airways Service at John Hunter Hospital, says monoclonal antibodies (also called biologics) that target specific inflammatory pathways to change outcomes in severe asthma are also showing similar promise in eosinophillic COPD.
GPs can help prepare patients for emerging biologic therapies by reviewing eosinophil counts, optimising standard therapies and considering specialist referral for patients with ongoing exacerbations despite treatment.
While the traditional understanding of COPD focused on permanent lung damage and fixed airflow obstruction, “we’re now recognising that there are different types of COPD, all of which have individual treatments,” Dr Tiedeman says.
“Historically, we used to talk about asthma and COPD as being completely different. But actually, we’re realising that’s probably an outdated way of considering things, particularly when it comes to people with eosinophilic exacerbations.”
This helps explain why some patients with COPD respond particularly well to inhaled corticosteroids and prednisolone, while others have limited benefit, she says.
Evidence linking eosinophilic inflammation to COPD outcomes has been accumulating for decades, Dr Tiedeman notes. Population studies from Europe, Canada and Korea have shown that patients with higher eosinophil counts experience faster declines in lung function and are more likely to develop airflow obstruction over time.
Large randomised controlled trials have demonstrated that biologics currently used in asthma are also beneficial in eosinophilic COPD for reduction of exacerbations.
“We are now recognising that if you have eosinophilic COPD there are new treatment options that will reduce your future exacerbations and potentially change your entire life,” Dr Tiedeman says.
In the MATINEE study, 804 COPD patients with a blood eosinophil count of at least 300 cells/μl who were receiving triple inhaled therapy were randomly assigned to receive monoclonal antibody mepolizumab or placebo over 52 to 104 weeks. It found the annualised rate of moderate or severe exacerbations was significantly lower in the mepolizumab than the control group, and a longer time to the first moderate or severe exacerbation (419 versus 321 days).
Similarly, the BOREUS study randomly assigned 939 patients with COPD, a blood eosinophil count of at least 300 cells/μl and a heightened risk of exacerbation despite being on standard triple therapy to receive either monoclonal antibody dupilumab or placebo for 52 weeks.
“What that demonstrated was that if you’re on dupilumab, you had a significant reduction in your cumulative mean number of exacerbations, which in turn reduces the amount of prednisolone these patients are requiring and the side effects associated with significant prednisolone doses,” Dr Tiedeman says.
Another promising finding is the improvement in FEV1, she says.
“The really exciting thing these studies, is not only do they reduce exacerbations, but they have also demonstrated an improvement in lung function in COPD. The historical teaching of COPD was these people have fixed airflow obstruction; this is as good as it’s going to get. But actually we’re showing these medications can improve lung function.”
This improvement probably results form a reduction in sputum plugging, which is an area of avid interest in respiratory medicine, she adds.
Research has consistently demonstrated that inhaled corticosteroids reduce exacerbation rates most effectively in patients with elevated eosinophil counts, and the higher the eosinophil count, the greater the benefit appears to be, Dr Tiedeman says.
Importantly, the GOLD guidelines released this year recognise the role of eosinophils in COPD treatment selection, she says.
“It’s the first time that we’ve finally acknowledged that patients who have eosinophils greater than 300 benefit from inhaled corticosteroid—and it should be added in relatively rapidly to their treatment,” Dr Tiedeman says.
Other green flags favouring the addition of an inhaled corticosteroid include a history of asthma, frequent moderate exacerbations requiring oral corticosteroids or antibiotics, or severe exacerbations requiring hospitalisation.
Conversely, patients with very low eosinophil counts (<100 cells/μl), recurrent pneumonia or a history of mycobacterial infection probably will not benefit, while those with an eosinophil count of 100-300 cells/μl may get some benefit, she adds.
Analyses from COPD trial populations suggest that between 25% and 45% of patients have significant eosinophilia and would benefit from biologics, Dr Tiedeman says.
She estimates that approximately 20% to 30% of patients with COPD could potentially qualify for biologic therapy after taking eligibility criteria into account.
“It’s not going to be all of our patients, but it’s actually going to be quite a significant proportion.”
In March, the Pharmaceutical Benefits Advisory Committee made positive recommendations for both mepolizumab and dupilumab, Dr Tiedeman notes.
Biologics for COPD, like those for asthma, require a prescription from a respiratory specialist.
As PBS arrangements evolve, she recommends identifying suitable patients, noting the first step is to check current and historical eosinophil counts.
“The great news is that you have an eosinophil count on every full blood count you have ever ordered for your patient. Patients with eosinophils greater or equal to 0.3 in the past 12 months and exacerbations should be considered for these new treatments,” Dr Tiedeman says.
The second step involves ensuring patients with elevated eosinophils receive appropriate inhaled therapy, with a LAMA, LABA and ICS.
“If the eosinophils are greater than 0.3, and the patient has symptoms and exacerbations, start a triple inhaler,” she says. It’s also essential to optimise inhaler technique and adherence, so it can be worth arranging a review with a practice nurse or pharmacist.
Specialist referral should be considered for patients with eosinophilia and ongoing exacerbations despite triple therapy, to assess suitability for advanced treatment options, including the new biologic agents.
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