Treatable Traits and Eosinophil Counts: Drug Therapy in COPD

Neil Skolnik, MD


April 06, 2021

This transcript has been edited for clarity.

I'm Dr Neil Skolnik. Today we are going to talk about the GOLD guidelines for COPD, focusing on pharmacologic management.

The GOLD guidelines can be a bit complicated. My goal is to make them simple and usable. If you are interested in more details, go to the full guidelines.

The management of COPD is guided by two treatable traits: symptoms and exacerbations. Exacerbations accelerate worsening of disease, interfere with quality of life, and increase mortality. Past exacerbations are the strongest predictor of future exacerbations. The guidelines use a quadrant approach for initial treatment.

There are three classes of inhalers for COPD; two are bronchodilators and the third class is anti-inflammatory inhaled corticosteroids (ICS). There are short-acting (albuterol and ipratropium) and long-acting bronchodilators (long-acting beta-agonists [LABAs] and long-acting anti-muscarinic [anticholinergic] agents [LAMAs]).

Bronchodilators primarily improve airflow and thereby reduce symptoms. They also decrease exacerbation and hospitalization rates. LAMAs are more effective than LABAs in reducing exacerbations. Although they improve symptoms, the most powerful effect of ICS is decreasing the frequency of future exacerbations.

Pharmacologic options include two bronchodilators in a single inhaler; a LABA/LAMA combination works better than a single bronchodilator in improving airflow. There are ICS-LABA combinations, and now triple therapy is available with a combination of LAMA, LABA, and ICS inhaler.

Let's talk about initial treatment recommendations:

  • For mild symptoms and a history of one or fewer moderate exacerbations (GOLD grade A), a single bronchodilator is recommended.

  • With a higher symptom burden (GOLD grade B), a LABA, LAMA, or dual-bronchodilator therapy (LABA/LAMA combination inhaler) is recommended.

  • With both a high symptom burden and two or more moderate exacerbations or at least one hospital-level exacerbation (GOLD grade D), start with either a LAMA, combination therapy with a LABA/LAMA, or a LABA/ICS.

With a history of asthma or asthma/COPD overlap syndrome, an ICS-containing medication should be used. New information in the guidelines describes the relation between eosinophil counts and ICS responsiveness. Patients with eosinophil levels below 100 cells/µL have a poor response to ICS, whereas those with progressively higher eosinophil levels display a better response to ICS.

Now let's talk about follow-up. Again, we are guided by treatable traits — dyspnea or exacerbations. If a patient's chief problem is insufficient symptom control and they are not already on dual bronchodilator therapy, they should be advanced to this treatment.

Patients who are experiencing exacerbations should be advanced to combination therapy if they are not already on it — either a LABA/LAMA or a LABA/ICS. Preference is given to adding an ICS if a patient's exacerbations have been more frequent, more severe, or the higher their eosinophil count is above 100 cells/µL. If a patient is already on combination therapy, consider advancing to triple therapy with a LABA/LAMA/ICS combination inhaler. Triple therapy has been shown to reduce mortality compared with dual-bronchodilator therapy when used in symptomatic patients with a history of frequent or severe exacerbations. If the eosinophil count is below 100 cells/µL, instead of adding an ICS, consider dual bronchodilator therapy with the addition of either roflumilast or azithromycin.

This is important information on an important disease.

I'm Neil Skolnik, and this is Medscape.

Neil Skolnik, MD, is a professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University and associate director of the Family Medicine Residency Program at Abington – Jefferson Health. He has published over 350 articles, essays, poems, and op-eds in the medical and nonmedical literature, as well as four medical textbooks and a book of short stories. In addition, he is the host of the American Diabetes Association's monthly Diabetes Core Update podcast. Follow him or direct-message on Twitter: @NeilSkolnik

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