Current Approaches to COPD Therapy According to GOLD Recommendations and in the Conditions of Czech Practice

COPD – A Common and Treatable Disease

In the Czech Republic, the prevalence of COPD in the adult population is estimated at 8%, but the real prevalence is likely higher. Annually, over 20,000 people are hospitalized for COPD in our country alone, and about 3,500 succumb to the disease every year.

COPD is a preventable and treatable disease, and its therapy is globally guided by international recommendations for the therapeutic strategy of the Global Initiative for COPD (GOLD). These have undergone a number of significant changes, which include a greater emphasis on phenotypic manifestations and prognostic factors in the form of symptoms and exacerbations.

Inhaled bronchodilators such as β₂-agonists (BA) and anticholinergics (MA) play a dominant role in COPD pharmacotherapy, with the most modern approach being the administration of long-acting or ultra-long-acting bronchodilators (LAMA, U-LAMA, LABA, U-LABA). Combined therapy represents the culmination of decades of development in COPD treatment. Bronchodilator preparations can be administered in free combination, but the trend is towards using dual fixed combinations.

Treatment Strategy According to GOLD

In the GOLD recommendations, spirometry is not a sufficient predictor of the state and prognosis of COPD and thus does not represent an important tool for pharmacotherapeutic decision-making. The ABCD categorization of the severity of COPD is based on symptoms and exacerbations in the past year. The preferred approach to treatment is the administration of LAMA or a LABA/LAMA combination, with dual fixed bronchodilator therapy brought to the forefront.

Historically frequent use of inhaled corticosteroids in COPD therapy is currently recommended for patients with a phenotype characterized by frequent exacerbations (categories C and particularly D) and for patients with an overlap syndrome of COPD and bronchial asthma. Monotherapy with inhaled corticosteroids is not recommended.

In category D patients, step-up and step-down pharmacotherapy can be applied, and the use of macrolides (in former smokers) and roflumilast (with forced expiratory volume in one second /FEV₁/ < 50% of the predicted value and the presence of chronic bronchitis) can be considered. The GOLD recommendations also emphasize therapy and prevention of exacerbations, which significantly increase morbidity and mortality in patients.

COPD Treatment Strategy in the Czech Republic

In our country, COPD is perceived somewhat differently, as a heterogeneous and phenotypically distinct disease. The goal of therapy is maximal individualization, with currently six main phenotypes being identified, which can combine in various ways. COPD therapy is, therefore, approached comprehensively and includes several steps:

• The first step is the elimination of risks, primarily smoking cessation.
• The second step is universal treatment that is common to all COPD phenotypes and includes pharmacological (bronchodilator therapy) and non-pharmacological approaches (rehabilitation, education, occupational therapy, nutritional and psychosocial support, vaccination, etc.).
• The third step is phenotype-targeted pharmacotherapy, which includes the administration of mucolytics, antibiotics, inhaled corticosteroids, roflumilast, or alpha-1-antitrypsin substitution (in the emphysematous phenotype with proven deficiency) alongside bronchodilators.
• The fourth step involves treating respiratory insufficiency and caring for patients in the terminal phase of COPD. This category includes long-term ventilatory support, lung transplantation, and in palliative care, primarily the administration of opioids.

(holi)

Sources:
1. Pauk N. COPD Treatment. Clinical Pharmacology and Pharmacy 2018; 32 (4): 15–20. 
2. Vogelmeier C. F., Román-Rodríguez M., Singh D. et al. Goals of COPD treatment: focus on symptoms and exacerbations. Respir Med 2020; 166: 105938, doi: 10.1016/j.rmed.2020.105938.
3. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2022 report). Global Initiative for Chronic Obstructive Lung Disease, 2021 Nov 22. Available at: https://goldcopd.org/wp-content/uploads/2021/12/GOLD-REPORT-2022-v1.1-22Nov2021_WMV.pdf
4. Zatloukal J., Brat K., Neumannová K. et al. Chronic obstructive pulmonary disease – diagnosis and management of stable disease; a personalized approach to care, using the treatable traits concept based on clinical phenotypes. Position paper of the Czech Pneumological and Phthisiological Society. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 164 (4): 325–356, doi: 10.5507/bp.2020.056.