A session at the 2018 European Respiratory Society (ERS) Congress debated whether doctors and patients with COPD were travelling in the same direction, unleashing some challenging ideas and a sense that patients might benefit from a ‘back to basics’ approach.
Professor Bartolome Celli, from Tufts and Harvard Medical School, told ERS International Congress delegates that he’d like to see some ‘humanomics’ in the era of ‘-omics’.
“Humans are not just a bag of genes with water. Not all diseases will be cured by changing genes and knowing your genes alone will not solve COPD.”
He said human behaviour, driven by factors such as perceptions, literacy and culture, are overlooked in the management of complex diseases such as COPD.
He reminded the audience that medication adherence was a low 6% in a 2016 prospective study of patients with COPD recently discharged from hospital.1
The study group included patients admitted to hospital for a COPD exacerbation and expected to be highly motivated to use their inhaler regularly and correctly.
The major determinants of poor adherence were found to be the presence of cognitive impairment, which affected the patient’s ability to remember to take the medication, and severe hyperinflation, which adversely affected drug delivery.
Professor Celli said human behaviour could be changed – and with relatively low- tech strategies.
Using the example of the 35% reduction in smoking rates in New York City since 2002 following media campaigns and other initiatives such as smoke free workplaces.
Another successful example of behaviour change was the improved adherence to antiretroviral therapy in HIV-infected Kenyans who received SMS reminders.2
Professor Dave Singh, from the University of Manchester, said doctors and patients did not share the same perceptions about COPD and the impact of the disease.
The 2017 MIRROR Study, which surveyed COPD patients, GPs and respiratory physicians, found doctors both underestimated and overestimated the importance of various symptoms compared to patients.3
For example, specialists were likely to place more importance on cough and dyspnea symptoms while patients were concerned about chest tightness, wheezing and fatigue.
Doctors also underestimated the fact that about 90% of patients were not completely frank with them during consultations.
The resulting communication gap between doctors and their patients was not in the interests of an effective doctor-patient relationship or good quality health care, said Professor Singh.
However, he said there was still plenty of room to optimise the management of COPD.
For example, there was a body of research in recent years demonstrating that patients typically experienced a diurnal variation in symptoms in COPD.
In a large US study, 61% of patients reported early morning and night symptoms – mostly moderate to severe – and impacting on activities of daily living, sleep, anxiety and health-related quality of life.4
This and similar findings suggest that achieving 24-hour coverage of symptoms might require different treatments such as giving bronchodilators once or twice a day according to individual need.
Speaking at the same symposium Professor Alvar Agusti, director of the Respiratory Institute at Barcelona’s Hospital Clinic, told delegates there were probably missed opportunities to intervene early in COPD.
“The traditional paradigm of COPD was a self-inflicted disease caused by tobacco smoking. But the dogma that all COPD is the same is wrong.”
He said the compelling evidence for early life influences on lung function trajectories highlighted instead the complexity and heterogeneity within the COPD population.
Of particular interest, the Tasmanian Longitudinal Health Study had demonstrated that early life disadvantage could be overcome as some children with initially low lung function achieved normal lung function by early adulthood.5
“Can we help other children to catch up or adults to catch up?” he asked the audience.
Importantly, that relied on identifying early life risk factors such as prematurity, maternal smoking and lung infections during medical history taking and perhaps implementing lung function testing in childhood.
Professor Klaus Rabe, director of pneumonology at Germany’s Lung Clinic Grosshansdorf, said well-intentioned tweaking of the GOLD COPD classification systems had failed to improve prediction of all cause or respiratory mortality.6
He also challenged the complexity of many guidelines, including Australia’s Stepwise Management of COPD, and called for clinicians to focus on individual patients.
In particular, there should be increasing recognition of the multi-morbidities in COPD patients.
The symposium was also told drug development should not just focus on iterations of triple therapy but continue to work on pharmacotherapy that could help patients with smoking cessation.
This article was based on presentations from ‘COPD Patients and doctors: travelling in the same direction’ a symposium hosted by A. Menarini Group at the 2018 European Respiratory Society Congress. The article covers presentations from;Professor Bartolome Celli, Professor Dave Singh, Professor Alvar Agusti and Professor Klaus Rabe.
This article was sponsored by A. Menarini Australia Pty Ltd, which has no control over editorial content. The content is entirely independent and based on published studies and experts’ opinions, the views expressed are not necessarily those of A. Menarini Australia Pty Ltd.
References
- Sulaiman 2016: https://www.atsjournals.org/doi/abs/10.1164/rccm.201604-0733OC
- Lester 2010: https://www.thelancet.com/article/S0140-6736(10)61997-6/abstract
- Celli 2017: https://www.ncbi.nlm.nih.gov/pubmed/28794623
- Stephenson 2015: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4368031/
- Bui 2018: http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(18)30100-0/fulltext
- Gedebjerg 2018: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(18)30002-X/abstract