Chronic obstructive pulmonary disease (COPD) is a leading cause of death globally, but ongoing explorations of the disease are rapidly informing treatment and prevention efforts. At CHEST 2022, pulmonologists reviewed some of the latest research during the session, Updates in the Management of COPD, on Monday, October 17.
MeiLan K. Han, MD, MS, professor of medicine at the University of Michigan, offered insights into the 2022 update to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report on strategies for the diagnosis, management, and prevention of COPD.
Dr. Han is a member of the GOLD Science Committee, which published the 2023 GOLD Report in November 2022. Because that report was still under embargo during the CHEST Annual Meeting, Dr. Han focused on the 160 new references in the 2022 document.
Notable updates from the 2022 GOLD Report
Among the updates included in the 2022 report were definitions of four distinct entities related to COPD—early COPD, mild COPD, COPD in young people, and pre-COPD—including an emphasis on distinguishing biologically early COPD from mild COPD.
The 2022 report outlined important vaccinations related to stable COPD and reducing serious risks to those patients. The report highlighted influenza vaccination, SARS-CoV-2 vaccination, pneumococcal vaccination, and even whooping cough and shingles vaccinations, which Dr. Han said should be on the radar of pulmonologists as much as they are for primary care clinicians.
Dr. Han reviewed recommended changes in the treatment and management of COPD, including the initial and follow-up pharmacological treatment of patients. Other updates detailed nonpharmacologic management options, such as smoking cessation and pulmonary rehabilitation, along with recommendations for follow-up.
Also notable, Dr. Han said, were an update addressing an upsurge in telerehab and a mention of mounting evidence that initiation of inhaled therapies in COPD may reduce the rate of lung function decline.
“I’m generally encouraged by the data that we have coming in on the existing therapies and on the impact they can have in COPD,” Dr. Han concluded, “although realizing that if we want newer and better therapy, studying these patients with early COPD will be really important.”
Update on biologics in eosinophilic COPD
Farrukh Abbas, MD, MBBS, assistant professor of medicine in the pulmonary and critical care division at Virginia Commonwealth University, opened the session with a discussion of biologics targeting airway inflammation in COPD.
“COPD is a heterogeneous disease, predominantly characterized by increased airway macrophages along with neutrophils and cytotoxic T lymphocytes,” Dr. Abbas said. “But about 15% to 40% of COPD patients diagnosed have increased eosinophils, even in the absence of asthma.”
Eosinophilic COPD reflects a distinct phenotype that is associated with higher risk of acute exacerbations, according to Dr. Abbas. The additional risk of pneumonia associated with inhaled corticosteroid treatment for eosinophilic COPD has led to increased interest in precision medicine and the proposed use of biologics.
Dr. Abbas detailed the outcomes of several recent trials of anti-IL-5 monoclonal IgG1 antibodies, including mepolizumab and benralizumab. Results were variable, with only one arm of mepolizumab trials showing improvements in moderate to severe exacerbations and no effect on severe exacerbations, lung function, or quality of life. Benralizumab showed no effect on moderate or severe exacerbations, lung function, or quality of life.
These data indicate that more studies are required to consider biologics in patients with eosinophilic COPD, Dr. Abbas said, noting that two such trials involving tezepelumab (COURSE) and dupilumab (NOTUS) are ongoing.
Update on alpha-1 antitrypsin-related COPD
Charlie Strange, MD, FCCP, professor of pulmonary, critical care, allergy, and sleep medicine at the Medical University of South Carolina, also updated attendees on COPD related to alpha-1 antitrypsin (AAT) deficiency. AAT deficiency (AATD) is a genetic disease in which low levels of the AAT protein can result in COPD.
Dr. Strange reviewed the mechanisms of this rare disease and the many barriers to its detection. Severe AATD often results in combinations of diagnoses, including emphysema, asthma, chronic bronchitis, and liver disease.
“AATD is widely underdiagnosed,” he said. “We think maybe 10% of the alpha-1 population is diagnosed in America today. That means 90% are in our COPD clinics.”
In reviewing data from studies, Dr. Strange remarked that outcome measures to study medications for emphysema progression remain torturous—costly and time consuming.
“I would love to have great trials in alpha-1 that mirror some of the COPD trials,” he said. “We just don’t have the patient volume to do that.”