COPD: Treatments, Non-Compliance, and Outcomes
Optimal pharmacological treatment for COPD patients reduces symptoms, reduces the frequency and severity of exacerbations, improve health status and increases exercise tolerance. Unfortunately, despite frequent changes in COPD classification systems and the emergence of new inhaled therapies recommended from evidence-based guidelines, poor adherence to treatment due to the cost of medication and lack of availability of medications create a gap in real-life prescribing patterns (Cases et al, 2018).
Types of inhaled medications
Inhaled medications form the foundation of pharmacological treatment for COPD. By using inhaled delivery it allows the doctor to target the medication to the airways enabling rapid effects with a relatively low dose of medication. There are several different forms of inhalation devices. They include MDI-metered dose inhaler, DPT-dry powder inhaler, SMI-soft mist inhalers, and SVN-small volume inhalers.
And while each device has its own unique attributes, insurance providers and pharmacy formularies are usually major parts of the choice by doctors. Also part of the equation is patient-centered considerations. Things such as COPD severity, other conditions present, cognitive function, and physical ability to use the inhaler are all important parts of compliance. Studies have shown that errors while using MDI or DPI are especially seen in the primary care setting and with elderly patients.
Device versus medication
two-prongy had a two-prong look at the problem focusing on both the patient and the health care provider. The findings of the study found important perspectives on the role of inhalation devices in COPD treatment. Both groups tended to place more importance on the actual medication than how it was the given-what delivery system they used. Discouragingly the ability to use inhalation devices were found to not be routinely assessed and inconsistent education given to patients to ensure proper use of the device.
Missed opportunity to teach
In addition, a majority of health care providers did not uniformly see poor technique as a significant barrier to the optimal management of the patients COPD. This is discouraging results. This study also found treatment changes were typically triggered by symptoms and exacerbations rather than poor device technique. This study uncovered several gaps in health care provider and patient understanding of the role of inhalation devices in COPD management. It also highlights unmet needs and opportunities for future intervention to promote proper device use and increase medication adherence (Hanania et al, 2018).
What is COPD
COPD is an umbrella term that covers a group of common respiratory disease. This group includes chronic bronchitis, emphysema, and asthma. The incidence of COPD is rising in the US and the disease represents a significant source of morbidity and mortality. In the US more than 13 million people have been diagnosed with COPD with another 24 million suspected of having undiagnosed disease. COPD is preventable, treatable, characterized by persistent airflow limitations that are usually progressive. Primary care providers are the main place of contact for patients with COPD and play a critical role in their everyday care. It requires an individualized approach for care to help with patient adherence and inhaler technique.
Issues with treatment
Now there are studies showing the usefulness of using an inhalation treatment with two bronchodilators for COPD management. Acute exacerbations can be extremely distressing for the patient and their family. It can also cause a financial burden on health care resources. It is important for health care providers to have an understanding of the variety of different agents and their device options in order to optimize personalized care of this group of patients and help them to experience increased adherence to the treatment plan (Anzueto & Miravitlles, 2018).
Promising treatment for increased mucous
Due to the chronic nature of this condition of this condition of COPD results in multiple doctor visits and hospital trips because of the increase in mucous with a decrease in ability to expel it. This problem can lead to a decrease in airflow causing difficulty breathing. Guaifenesin (Mucinex, Robitussin Plain, Triaminic Chest Congestion) is an over the counter medications that work to thin secretions making them easier to be coughed out. It can also be used in children to help with coughing but needs to have guidance from a doctor for proper dosing. It is classified as an expectorant and loosens chest congestion making it easier to cough out. It is available in pill form as well as liquid. If using liquid form it is suggested that the patient make use of the measuring device that comes with the bottle. If it isn’t available ask the pharmacy for one.
This study took a look at an alternative to prescription medications to help deal with an ever-present cough, mucus production, and chest congestion noted with many patients who have COPD and asthma. It followed a case study of an 82-year old female seen in their practice that had a history of COPD under treatment for 20 years. The doctors had tried multiple rounds of antibiotics and bronchodilator medications with little improvement. Prior to adding the Guaifenesin, her forced expiratory volume in one second was only 82%.
After being on Guaifenesin and dextromethorphan (for cough) available as Mucinex DM, for three months her FEV1 increased to 92%. She also reported she was able to breathe easier with a noticeable increase in the amount of mucous she expelled. Even after stopping her Mucinex DM, the improvement continued and her exacerbation frequency went from every two months to every four.
Suggestions from study
This is hopeful for patients COPD bothered by increase production of mucus. It is felt the Guaifenesin may directly influence cells of the respiratory tract as it decreases mucous viscosity and promoting more effective coughing. It has also been found to inhibit the cough reflex sensitivity so when the patient coughs there is a greater chance of it being productive. While this needs further study to validate the findings it is encouraging for those who have COPD but can’t always afford the prescribed medication (Storm & Miller, 2018).
Problems with adherence to therapy
In both asthma and COPD adherence to treatment represents a pivotal aspect in long-term care. Analysis of indicators highlights the appropriateness and adherence levels to be improved for several therapeutic areas. Over recent years much attention has been given to the personalization of treatment in the management of many respiratory diseases, including asthma. This type of treatment includes approaches of management of a single patient. This also takes into account the kinds of inhalers and not only the best ones for their condition but also the ones the patient can most effectively use. This approach helps to increase adherence because the patient will be more able to use the inhaler. This study also discussed the problems of the cost of medicine play an important part in compliance of patients.
Barriers to adherence
Just because the medication is the newest and best one for the condition it doesn’t mean the patient can afford it. The aim of COPD management, including asthma, is to control symptoms and reduce future risk. It is a future-looking doctor that sees the importance of matching the proper medication to the individual who can most use it. Poor adherence to inhaled corticosteroids therapy is seen as a contributing factor to the failure of treatment. Often this is because the patients can’t afford the medication and/or their insurance won’t cover it (Donner et al, 2018). Non-compliance or adherence to inhaler medication is a common therapeutic problem in patients treated for COPD and asthma. This study was conducted to explore the level of adherence and the frequency of factors for non-adherence.
Further issues with non-adherence
As with other chronic treatment regimens, non-adherence to therapy is widespread. Some of the negative consequences of this non-compliance includes poor symptom control, increase risk of hospitalization, worsening quality of life, increased health care expenditure and two to three times higher mortality rate. This study found that those with inhaled medications were in poor compliance and these included economic issues (can’t purchase the medication due to cost), health literacy (didn’t know they were supposed to take the medicine on a regular basis or not), fear of dependence on inhalers, or side effects when they were used and didn’t want to bother the doctor.
The economic problem is the most frequently stated reason for non-adherence begs the question how can these medications be made more affordable and available to those patients whose very life can often depend on them? Patients with either no insurance or insurance that won’t cover the inhalers are the ones who are in most need and are the least able to afford them. Common pharmacological problem of non-adherence is an issue in the US and around the world. It has become a political issue in our country and because of the policies of the pharmacological community; prices will continue to climb out of reach of those in most need (Ahmad et al, 2018).
Ahmed, H. et al. (2018). Adherence to inhaler medications in patients treated for asthma and COPD. Pakistan Journal of Chest Medicine,24(1).
Anzueto, A. & Miravitlles, M. (2018). The role of fixed-dose dual bronchodilator therapy in treating COPD. The American Journal of Medicine,131(6).
Casas, A. et al. (2018). Respiratory medication used in COPD patients from seven Latin American countries: The LASSYC study. International Journal of Chronic Obstructive Pulmonary Disease.
Donner, C. F. et al. (2018). Inhalation therapy in the next decade: Determinants of adherence to treatment in asthma and COPD. International Journal of Cardiopulmonary Medicine and Rehabilitation,88 (1).
Hanania, N.A. et al. (2018). The role of inhalation devices in COPD: Perspectives of patients and health care providers. Journal of the COPD Foundation,5(2).
Storms, W.W. & Miller, J.E. (2018). Improved lung function and quality of life following guaifenesin treatment in a patient with COPD: A case report. Respiratory Medicine Case Reports.