Tackling COPD: a Multicomponent Disease Driven by Inflammation

Peter Kardos, MD; Joseph Keenan, MD

Disclosures
In This Article

Abstract and Introduction

Abstract

In recent years, research has revealed more about the factors underlying the pathogenesis of chronic obstructive pulmonary disease (COPD). In particular, inflammation in the lungs leads to the structural changes observed in COPD, while extrapulmonary symptoms and comorbidities may be systemic manifestations of these inflammatory processes. A new multicomponent disease model is proposed that takes into account all elements that should be considered in treatment decisions. Current monotherapies act on different aspects of COPD and may not address all components. A combination of a long-acting beta2-agonist and an inhaled corticosteroid has complementary effects, addressing a wider range of components of COPD. This combination appears to have greater clinical benefits than either agent alone in reducing the frequency of exacerbations, reducing the number of hospitalizations, and potentially promoting survival. Minimizing the burden of COPD within — and potentially outside — the lung means treating patients early and addressing as many disease components as possible.

Introduction

Chronic obstructive pulmonary disease (COPD) is characterized by inflammation, airflow limitation that is not fully reversible, and a gradual loss of lung function.[1] The latest American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines also note significant systemic consequences.[1] COPD is a common, costly, and preventable disease that presents challenges in primary care. General practice consultation rates for COPD in the United Kingdom are 2 to 4 times the equivalent rate for angina, illustrating the burden of this disease in primary care practices.[2] Nonetheless, in primary care both the impact and importance of COPD seem to be broadly underestimated. Primary care physicians (PCPs) are the first point of contact in the detection and management of the COPD patient, and in the introduction of important preventative interventions such as smoking cessation. Furthermore, PCPs can play a vital role in early detection through "case-finding strategies" — probably the only cost-effective way of detecting COPD at an early stage.[3]

The number of patients with COPD is estimated at 600 million worldwide and is increasing.[4] Between 1990 and 1997, the prevalence in the United Kingdom increased by 25% in men and 69% in women (Figure 1).[5] COPD is the fourth leading cause of death in Europe and the United States[1,6] and represents a major economic burden. In Europe, the total direct and indirect costs of COPD every year are around 50 billion pounds — almost half of the total costs of lung disease.[2] Yet these figures probably do not represent the extent of the challenge because airflow limitation in general — and COPD in particular — may be under-recognized in patients who attend general practices for other reasons.[7,8] COPD can also be misdiagnosed as asthma, or not diagnosed until at a very late stage of disease.[9]

Figure 1.

Prevalence of physician-diagnosed chronic obstructive pulmonary disease in the United Kingdom.[5] Reproduced from Soriano JB, et al. Thorax. 2000;55:789-794, with permission from the BMJ Publishing Group.

COPD is preventable and treatable, but like asthma or coronary heart disease, it is not curable. Although current treatments such as smoking cessation can slow COPD progression, they cannot alter its irreversible nature. Therefore, when considering new therapies for COPD, it is particularly important to examine the factors involved in the pathophysiology of the disease. The complex pathophysiology of COPD involves multiple components that contribute to inflammation and airflow limitation, both of which are present at all stages of the disease. During the course of the disease, this translates into a decline in lung function and an increase in symptoms and exacerbations that affect patient health and, ultimately, survival.[10] COPD also has a major impact on quality of life.[11] When deciding on the most appropriate approach to management and treatment, it is important to consider the components that contribute to the disease in order to best improve the lives of patients.

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