COPD has a dramatic impact on patients and public health. In the United States:
Appropriate guideline-based selection and use of medications for the treatment of COPD can improve patient outcomes and quality of life as well as reduce the risk of exacerbations and hospitalizations.
Currently available medications used in the management of COPD do not change the progressive decline in lung function that is associated with the disease. Instead, the goals of pharmacotherapy for COPD include improving symptoms and decreasing exacerbations.
Several classes of medications are used to manage COPD (Table 1). Guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) provide recommendations for the treatment of COPD and include guidance regarding the role of each class of medication in therapy (http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd).5 According to these guidelines, medication selection is based on patient risks and symptom score, as measured by a validated assessment tool, and risk of future exacerbation, including frequency of exacerbations and hospitalizations:5
Most of these medications are delivered via inhaler and/or nebulizer. Theophylline and roflumilast are taken orally.
Pharmacists can help improve outcomes for patients with COPD through several strategies, including the following approaches:
Patients require frequent and ongoing education about the management of COPD. Patient education should occur at diagnosis, during follow-up visits throughout the course of the disease, and when supporting patients during transitions of care. Pharmacists can ask patients open-ended questions to engage them regarding several topics that are important to the management of COPD (Table 2).
These questions are effective for eliciting information about the patient’s needs so that a plan can be developed to address those needs. Once education is provided to the patient, the “teach-back” technique is often helpful for ensuring that a patient understands the information. A good way to approach this is to say, “We just went over a lot of information and I want to make sure I didn’t forget to mention anything. Will you please explain what I said back to me?” Listen to the patient explain what he or she heard, and then clarify the information as needed.
The National Heart, Lung, and Blood Institute—part of the National Institutes of Health—provides materials to support the care of patients with COPD. These resources are available at https://www.nhlbi.nih.gov/health/educational/copd/campaign-materials/index.htm.
Medication therapy management services designed to ensure patients understand which medications should be used when, and how to use those medications, are a key component of the treatment and management of COPD. Patients with COPD may be hospitalized for the treatment of exacerbations and they can experience high readmission rates. Reviewing the patient’s medication regimen and educating the patient and caregivers during transitions of care can not only
improve patient care but may reduce the risk of readmissions.7 Pharmacists can positively affect patient care throughout transitions of care by reviewing all aspects of the patient’s COPD management, ensuring that the patient is using appropriate medications correctly, and assessing and addressing other behaviors that impact COPD outcomes.
Medication reconciliation services designed to review a patient’s medication treatment regimen should be a key component of transition of care services. Such services are crucial for identifying and addressing adherence issues. Poor adherence has been associated with unnecessary escalation of therapy and reduced quality of life as well as increased morbidity, health care expenditures, hospitalizations, and possibly mortality.8 Medication adherence interventions should address both the medication regimen and the use of inhaler devices to support proper technique.
Correct use of inhaler and nebulizer devices is crucial for the efficacy of inhaled medications. However, research indicates that up to 85% of patients use their inhalers for COPD ineffectively.9 Because of the importance of inhaler technique, regular evaluation of inhaler technique has been added to the recommendations in the GOLD 2017 guidelines. According to the guidelines, inhaler technique should be assessed at each visit to ensure the patient is able to use the inhaler correctly.
Pharmacists’ knowledge of correct inhaler and nebulizer technique, thorough patient education and demonstrations, and follow-up assessment skills are instrumental in optimizing device competency and medication adherence. Research has shown that patients’ inhaler technique improves following education from a pharmacist.10,11 Numerous educational tools are available to support efforts to train patients to correctly use their inhalers. For example, free training videos in multiple languages for over a dozen inhalers are available at http://use-inhalers.com. Many nebulizer manufacturers offer instructional videos; refer to specific device manuals for more information.
When selecting a device for medication delivery, there should be careful consideration of the needs, abilities, and limitations of the individual patient. Patients may be more likely to adhere to COPD therapy if their inhalers are simple to use and manage.12 This may be particularly true for older patients with COPD who have impaired physical and cognitive function that interferes with device adherence and proper use.13 If a patient is struggling with the use of their inhaler, the pharmacist may want to discuss options to switch to an alternate device (such as another inhaler or nebulizer).
Ideally, individual patients will be able to receive all inhaled medications via similar devices. Multiple inhaler devices that require different inhalational techniques may be confusing for the patient and result in administration errors. Additionally, switching among inhaler devices can have a negative impact on patient care if patients become confused about appropriate device technique.12 If a patient requires any medication changes that affect the type of device used to administer a medication, the pharmacist should assess the patient’s ability to use the new device and provide education about the new device.
The cost of treatment is an important consideration that affects access to care. Formulary and coverage determinations, prior authorizations, and tiered copays are common practices for managing costs associated with some of the medications and devices used to treat COPD. Although such practices may control medication costs, they also may have a negative impact on patient care if they disrupt or delay patient access to medications and thereby interfere with patients’ ability to adhere to recommended pharmacologic therapy and maintain control of their COPD. Pharmacists can help address these barriers by working with patients and third-party payers to minimize medication access issues. Strategies include:
The American Pharmacists Association (APhA) gratefully acknowledges the financial support from Mylan Specialty, LP, for the development of this resource, Focus on COPD: Pharmacists Helping Patients Improve Outcomes and Reduce Readmissions.
The following individuals served as APhA content developers and pharmacy practice advisors:
Although every reasonable effort is made to present current and accurate information for public use, APhA and its employees and agents do not make any warranty, guarantee, or representation as to the accuracy or sufficiency of the information contained herein, and APhA assumes no responsibility in connection therewith. The information referenced in the document is provided “as is” with no warranties of any kind. APhA disclaims all liability of any kind arising out of the use of, or misuse of, the information contained and referenced in this document. The use of information in this document is strictly voluntary and at the user’s sole risk.