HPD 2024: Czech data from real-world practice confirm that mucolytic treatment can reduce COPD exacerbations, even in the future
Chronic obstructive pulmonary disease (COPD) is a global issue. Does it create the same burden everywhere? How does it contribute to premature deaths? How do women cope with COPD, and what significant problem does it pose for them? What factors contribute to it not being considered solely a smoker's disease? Why is it appropriate to add mucoactive agents when trying to eliminate COPD exacerbations? What emerged from early COPD screening conducted in the Czech Republic, and what do Czech real-world data show regarding the effectiveness of erdosteine in exacerbations? And what should be included in the proper diagnosis and treatment of this disease? All these topics were covered in a lecture by the head of the Pulmonary Clinic of the Medical Faculty of Charles University and University Hospital Hradec Králové, Associate Professor Vladimír Koblížek, M.D., Ph.D., during the XXVIII Hradec Pneumology Days held from April 24-26, 2024.
One of the Main Reasons for Premature Deaths
COPD affects all countries worldwide, albeit differently – depending on the region. Occupational COPD, for instance, is often overlooked even in most European countries. The impact of COPD also varies among countries, not merely due to costs. For instance, in Central and Eastern Europe, from Austria to Russia, there are extreme disparities in the number of pulmonologists or hospital beds; some countries in Central Europe may leave COPD patient care to general practitioners, while others – including the Czech Republic – primarily to specialists.
In Great Britain, it has been shown that a significant portion of COPD-related deaths occur due to repeated exacerbations and prematurely (before the age of 75). COPD is one of the primary causes of premature deaths globally, affecting both sexes. It is definitely not just a smoker's disease. The less developed a country is, the fewer the patients with COPD due to smoking, and vice versa.
All differences between countries concerning COPD must be considered when searching for a global management and prevention strategy. European data are quite similar, but the strategy of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) will hardly be uniform, as the world is very diverse.
Risk Factors
In a global context, Europe is among the regions where severe air pollution poses a problem – here the speaker highlighted the work of journalists from the Guardian, who, based on data from numerous measuring stations across Europe and even from space, found that only Scandinavia, Estonia, and Scotland meet the new WHO criteria for fine particulate matter pollution.
COPD in non-smokers affects all age groups; however, the older an individual gets, the higher their risk. This risk increases with decreasing socioeconomic status, and underweight (BMI < 18 kg/m2 is very risky) is also a risk factor. Risks vary in urban versus rural areas. The development of COPD in non-smokers is also related to acute respiratory disorders, chronic bronchitis, any asthma diagnosis at an earlier age (particularly problematic up to 8 years old, when the lungs are still developing), a family history of lung diseases, and cardiovascular comorbidities.
A Bigger Problem for Women
Today, COPD should not be viewed as a disease only affecting male smokers. According to the COPD Foundation in the USA, the male dominance among COPD patients is disappearing, and it is becoming more of a problem for women – 6% of American women and 4% of men suffer from it. Women in the USA are twice as likely to be diagnosed with chronic bronchitis and significantly more often seek emergency help due to acute COPD exacerbations.
Moreover, women tolerate COPD worse than men. At least five major studies clearly declare that female COPD is associated with significantly diminished quality of life and a measurably higher presence of depression and anxiety at any stage of the disease. Women experience more significant declines in lung function, more frequent exacerbations, and more breathlessness, while men more commonly experience cough and sputum production. Any drop in FEV1 is also associated with the risks of other diseases, such as osteoporosis, which predominantly affects women, whereas men are more prone to cardiovascular diseases.
The speaker highlighted a publication in the journal Frontiers in Medicine, which examined how clinical presentation and the physiological impact of COPD differ between men and women. The study noted that the subjective and objective impact is worse in women. Furthermore, COPD is more often underdiagnosed in women.
The Importance of Early Diagnosis in a Czech Pilot Study
Timely diagnosis is critically important for the successful management of COPD. Between 2018 and 2022, a pilot study was conducted in several Czech centers, involving early screening for COPD among symptomatic patients. A total of 942 individuals were enrolled and examined by a pulmonologist, of which 270 were referred by general practitioners and 672 participated voluntarily.
Among the at-risk group of people aged ≥ 40 who had a history of smoking at least 10 pack-years or had other risks such as occupational exposure and experienced difficulties climbing one or two flights of stairs or walking briskly on flat ground, 35% had previously undiagnosed COPD. Of the patients referred by general practitioners, COPD was confirmed in 26.3% of cases, and of those who sought screening voluntarily, 41.1% had undiagnosed COPD.
The Crucial Role of Exacerbations and Their Management
The most significant issue regarding mortality and the impact of COPD is exacerbations. Hospitalizations still account for the majority of COPD-related costs. Data from Japan, Britain, the USA, Germany, and the Czech Republic indicate that patients with rapidly declining lung function predominantly experience exacerbations.
There is no universally accepted global definition of mild, moderate, and severe exacerbations. In the Czech Republic, it is generally considered that a patient hospitalized for this reason has severe exacerbations; if they use corticosteroids or antibiotics, they are experiencing moderate exacerbations, and the rest are classified as mild. The Roman protocol is very useful in differential diagnosis, as it helps to clarify that not everything that appears to be a COPD exacerbation necessarily is (it could be heart failure, pneumonia, pulmonary embolism, or even a single patient having all these diagnoses together).
In the prevention of exacerbations, dual or triple combinations including long-acting muscarinic antagonists (LAMA), long-acting beta2-agonists (LABA), and inhaled corticosteroids (ICS) are used, to which other medications may be added. A wide range of these drugs is available in the Czech Republic (PDE4 inhibitors, biologics, macrolides, antioxidants such as erdosteine, and others). Evidence is growing that these medications, when added to inhalation therapy, can significantly reduce the incidence of exacerbations.
The Czech Multicentric Research Database of COPD brought real-world practice data in this regard, based on an eight-year follow-up of 784 patients from 14 centers. Patients with a high incidence of exacerbations were given erdosteine in addition to their existing therapy, while those without exacerbations or with few occurrences remained without erdosteine and formed the control group. The number of exacerbations with erdosteine equalized over four years (in both groups, the annual incidence was 0.89), and this state persisted in the fifth year. This real-world practice study confirmed that the effect of erdosteine in mitigating exacerbations is real and effective.
5 Steps to Diagnosis, 5 Steps in Therapy
Proper diagnosis and treatment of COPD require five steps:
During diagnosis, it is essential to consider inhalation risks, detailed symptomatology (including history), conduct proper pulmonary function tests, and measure the Z-score, even though it is not included in the GOLD guidelines. The fourth step involves laboratory tests, and the fifth includes imaging methods – here, the speaker advocated for conducting low-dose or even standard CT scans if the patient's condition is concerning or worsening, as CT can reveal many aspects hidden from routine chest X-rays.
In terms of therapy, the first step is risk elimination (such as changing a job causing difficulties, quitting smoking, etc.). The second step is basic treatment, including LAMA, LABA, possibly vaccination, and regular exercise. The third step is treating all manageable markers or clinical phenotypes. The fourth step involves treating respiratory failure and palliative care, and the fifth encompasses interventions for all comorbidities.
Mucolytic medications can be administered long-term in at least three COPD phenotypes, representing one of the options to reduce the number of exacerbations even into the future, as shown by the aforementioned Czech real-world data.
Eva Srbová
Editorial staff of proLékaře.cz
Source: Koblížek V. Health inequality in view/approach to COPD. XXVIII Hradec Pneumological Days, Hradec Králové, April 24-26, 2024.
Did you like this article? Would you like to comment on it? Write to us. We are interested in your opinion. We will not publish it, but we will gladly answer you.
