CEimpact Podcast

Updated GOLD Guidelines for COPD

Share episode

Explore the latest GOLD guidelines for COPD management and discover how these updates can transform your patient care approach. In this episode, we break down key changes, practical applications, and evidence-based strategies to improve outcomes for your patients. Listen in and empower yourself to take a proactive role in optimizing COPD management in your practice.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

GUEST
Allison Hursman, PharmD, BCGP, CTTS
Population Health Pharmacist
Essentia Health
 
Pharmacist Members, REDEEM YOUR CPE HERE!
 
Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)


CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Explain the rationale behind key evidence-based recommendations in the updated COPD guidelines.
2. Describe the intended impact of these updated COPD guidelines on disease management.

0.05 CEU/0.5 Hr
UAN: 0107-0000-24-309-H01-P
Initial release date: 12/9/2024
Expiration date: 12/9/2025
Additional CPE details can be found here.

Follow CEimpact on Social Media:
LinkedIn
Instagram

Speaker 1:

Hey, ce Impact subscribers, welcome to the Game Changers Clinical Conversations podcast. I'm your host, josh Kinsey, and as always, I'm excited about our conversation today. The latest updates from the gold guidelines for COPD are set to reshape how we approach this complex disease. Staying current on these changes empowers pharmacists to make a real difference in patient outcomes, so let's dive into what's new and why it matters for your practice. It's so great to have Allison Hurstman as my guest expert for this episode. Welcome, allison. Thanks for joining us. Before we jump in, can you tell us a little bit about yourself and maybe your current role in PracticeSite, and also maybe why you are so passionate about this?

Speaker 2:

Yeah, so my name is Allison Hurstman. I have worked in a variety of different roles in my career, so I started in community and then I took a role that was a faculty joint position with an ambulatory care practice site, and so in both of those roles both in community and as well as this ambulatory care practice site I saw a lot of patients with COPD. Elderly patients are a huge population for both of those groups. More recently now I have transitioned to a role in population health, and so I work more on quality metrics and looking at ensuring all of our patients have really good quality care and are meeting guideline expectations that way. So COPD is something that I taught when I was in academia and it's just something that I've used a lot in my career, so something that I've kind of become passionate about.

Speaker 1:

Awesome, that's great. Well again, thanks for sharing about yourself and thanks for joining us today. It's so great to have you with us. So, as I mentioned, we're going to take a deeper dive into the GOLD guidelines and their recent updates. But first I'd love for you, if you don't mind, just to kind of set the foundation for our listeners, just kind of giving us an overview of COPD, maybe just a reminder of what it entails and maybe its prevalence that we're currently seeing in patients.

Speaker 2:

Sure. So COPD is a progressive lung disease. So in normal people, everybody about age 25, our lung function actually starts to slowly decline with age, and I know I'm 25.

Speaker 1:

I don't remember that statistic from school.

Speaker 2:

Yeah, very slow decline typically is what we see People with COPD they'll have an accelerated decline and it's an accelerated decline specifically in that FEV1. So if you remember back that FEV1 is, how much can you breathe out really quickly in that first second? And so we use spirometry in order to determine if there is that accelerated decline. And with COPD it's not reversible with that bronchodilator. So when we think about asthma, asthma we use a bronchodilator and it gets better COPD we don't see that reversibility.

Speaker 2:

Now, copd is quite prevalent. It's the third leading cause of death worldwide and I feel like we often associate it yeah, overlook, and we often associate it with a history of cigarette smoking, but it certainly is not always associated with cigarette smoking. It's a big public health challenge because of that link to tobacco use and cigarette smoking and it's largely preventable smoking and it's largely preventable. They also expect that the prevalence is going to increase in upcoming decades just because of our aging population and exposure to some of those risk factors. So, whether it's the cigarette smoking or pollutants, when we think about more of impoverished countries that maybe do a lot of cooking over a wood fire stove, that sort of thing, that can also contribute to progressing.

Speaker 1:

Okay, interesting. Wow, I learned two very, very bold things and you're opening credits there. This is, this is great, awesome. Thanks for sharing that. Tell us a little bit about the gold guidelines. How long have they kind of been around? Do they strictly tell us about COPD, or is it other breathing issues or whatnot?

Speaker 2:

So if you want to just kind of give a brief overview, yeah, so GOLD stands for Global Initiative for Chronic Obstructive Lung Disease, so they are specific to COPD and it is a global guideline. So that's something that's different. It's not just the US, it's a global guideline, which kind of becomes important because when they talk about medications in the guidelines, sometimes there are things that are available here in the United States and sometimes they include things that are not. They may be available in Europe or other parts of the world. The gold guidelines are kind of nice in that they do update on a yearly basis. Typically, updates come out in roughly November. So very shortly here they'll be releasing the 2025 version of the gold guidance document and they've been around for many, many years. We saw some more major changes occur in the 2023 edition that was released, you know, late 2022. And they're really these guidelines are the guidelines that are pretty much accepted as the gold standard, the gold guideline globally, if you will.

Speaker 1:

Okay, great, that's great. So the most recent changes would have occurred then, you know, several months ago. So what, what were some of those, or were there any? Was there anything really significant? Yeah?

Speaker 2:

So they made a few really significant changes. Historically, when we classified COPD, we had an A, b, c or D classification. Now A was for those patients who didn't have very many symptoms and also were not having exacerbations or hospitalizations, and it kind of sat in like a quadrant. So it went A and then B was the next quadrant over, and B was for our patients who were symptomatic, still not having exacerbations or hospitalizations. Now C and D were for the patients who were having the hospitalizations and the exacerbations, and so then C was no symptoms, D was both symptoms and the hospitalizations were exacerbations. So the changes that they made they combined group C and D and now they call them class E E for exacerbation. And what they found was there wasn't really any sort of clinical difference between class C and class D, so there wasn't really any benefit to separating those patients out.

Speaker 2:

And so with that they also changed what we should use for treatment. Historically they always said pretty much every patient with COPD needs to be on some sort of bronchodilator, and so there's a couple of different options when we think about bronchodilators. We have our short-acting beta agonists, we have our short-acting muscarinic antagonists. So your sabas, your samas, we also have the long-acting versions of those, and so anybody right now in the new guidelines, anybody who's not in group a, so no, pretty much no symptoms and also not having any exacerbations or hospitalizations. They've changed the guidelines to be more simplified in that they all should be on a Lava and a Lama, so combination therapy pretty much right off the bat.

Speaker 2:

Previously some patients got Labas, some patients got Lamas and anyone who really wasn't a pulmonologist probably was prescribing the wrong thing for them, describing the wrong thing for them. They say that the llamas prevent more exacerbations than the llamas. But they found that the combination is actually better than either agent as monotherapy. That's why they kind of moved, took that combination therapy recommendation for everyone.

Speaker 1:

What you brought up.

Speaker 1:

If I can interject really quick, one thing that you mentioned, obviously, is that it's global. What I didn't dig into was who is like. Who is on this board Is it like? Is it mainly made up of individuals from the States, or is it pretty equal representation from across the world? Because I guess my question is when you say they looked at you know these patients and these patients reacted best, or you know whatever, is that the majority of the United States patients or is that a very small percentage of what they looked at?

Speaker 2:

Yeah, so when they pull the literature for the gold guidelines, it's made up of a global panel of experts, if you will, and they will pull everything that has been published within the last year in the literature. So they will tell you exactly what things they search for in the literature and they actually review any new literature that's come year in the literature. So they will tell you exactly what things they search for in the literature and they actually review any new literature that's come out in the past year and try to determine if they need to make any changes to treatment recommendations based on any new literature that's coming out. So I do feel like it's pretty representative of you know, yeah, the globe and what's happening globally. Great question, yeah.

Speaker 1:

Okay, yeah, interesting. Okay, great, sorry, that just popped in my head and I wanted to be sure I asked it. So we were talking a little bit about then the combination therapy of LABAs and LAMAs.

Speaker 2:

Was there anything else significant with those most recent changes? As far as treatment, yeah, they used to sometimes recommend using an inhaled corticosteroid in combination with a LABA for some patients, and they have now phased that out as well. So they have found that the triple therapy with the inhaled corticosteroid, laba and LAMA has shown a better reduction in all-cause mortality, and so any patients who need to be on an inhaled corticosteroid they say just to do the triple therapy with now. So that's another pretty significant change. The other thing that they've adjusted is the follow-up treatment, and I feel like they simplified that as well, which is nice, because we have a lot of COPD patients who are managed by their primary care and not necessarily seeing pulmonology or that. So the biggest thing that they recommend is that they want all patients to be on that LABA-LAMA combination. So we have certainly a lot of patients who are just on a LABA or a LAMA per the previous guidelines, and if they're having symptoms or exacerbations now, they want you to step that up and do the combination therapy.

Speaker 2:

The piece that I feel like is really confusing and kind of sets COPD apart from asthma, is that in asthma we're always relying on that inhaled corticosteroid right? Asthma is that inflammation of the lungs and we need to keep that inflammation under control. And so they really stress that inhaled corticosteroid In COPD. If we're using inhaled corticosteroids, the patients have an increased risk of pneumonia and so obviously we don't really want pneumonia happening in our COPD patients because that can lead to exacerbations and disease progression. So if patients do not have an elevated eosinophil count, they want to avoid that inhaled corticosteroid. So there's a very specific population that they're going to use that triple therapy, that inhaled corticosteroid Lava Llama with. But they have really nice algorithms, if you pull up the guidelines, to be able to follow to step up that therapy and ensure that you're prescribing the right products for patients.

Speaker 1:

Great, okay, that kind of leads us right into our next section that I wanted us to tackle. You mentioned a lot of patients are not being seen by pulmonologists and I hope I'm not assuming incorrectly, but I would assume that some of them are probably not on the right medications because of that, potentially, what are the opportunities for pharmacy teams? Like, what should we be looking for? Should we be seeing medications that we're filling? Or when we're seeing patients come in with their medication list and asking those deeper questions and then should that lead to, are you being seen by specialists? Or I guess what are the opportunities for us with this information and knowledge that pretty much anybody who has COPD that comes across our desk should be on a Lava and a Lama? Like, what should we do when we don't see that happening?

Speaker 2:

Yeah, I think that's a great call out and a great question.

Speaker 2:

So, you know, we know that that combination therapy with that Lava Lama is the best for exacerbation prevention, and I think that we've all probably experienced, whether you're working in the community pharmacy setting or more of an ambulatory, or even in the hospital, you'll be visiting with a patient and maybe they came in from the parking lot and they're just so short of breath by the time they even get to the counter that they need to sit down and rest or they can't even carry on a conversation with you because of the amount of breathlessness that they have.

Speaker 2:

So I think that's a really great opportunity to maybe look yourself and say, okay, what are they on for medications? Does this look appropriate, you know, do they have asthma? Do they have COPD? What does it look like we're treating with their medication regimen? And then have some dialogue with the patient and find out, you know, like, is this a random thing that maybe you're just, you know, having a bad day today, or are you always, you know, struggling with breathlessness? Yeah, there's a couple of different like technical assessments that the guidelines recommend that you can use to assess breathlessness, and one of them is strictly like an assessment of the breathlessness the other one actually talks about, like quality of life and the impact of not being able to breathe on just doing daily activities Like can you get dressed without being out of breath, and that sort of thing.

Speaker 2:

So that breathlessness is, I think, a huge thing that you know anybody can recognize. You don't need a stethoscope, you don't have to listen to lung sounds to be able to pick out some of those patients you don't need a stethoscope.

Speaker 1:

You don't have to listen to lung sounds to be able to pick out some of those patients. Well, and like you said, that would be super easy for you know the pharmacy team to notice, or to notice that there's. You know, this is not how Mr Jones usually presents, Like he seems extremely out of breath. Is there something else going on? So yeah, I think that's a great point.

Speaker 2:

Yeah, and then I think you you know you pointed to this as well, but if you know, if this is something that you're seeing routinely, asking those questions and finding out, hey, are you, are you going to pulmonology just to ensure that they are being treated appropriately? You know, if we have patients who have both asthma and copd they used to call it asthma, copd overlap and they have kind of moved away from that verbiage now but patients with both asthma and COPD I do want to point out that those patients should be on that inhaled corticosteroid still. So there certainly are patients who do kind of need that inhaled corticosteroid. So I wouldn't say, like anytime you see an inhaled corticosteroid in a patient with COPD, to like, yeah, try to stop it necessarily, but maybe ask some more questions and find out.

Speaker 2:

And certainly like. If you have a patient who's on that inhaled corticosteroid LABA combination and they are a COPD patient, knowing that we're now supposed to be using that triple therapy, that would be a good place where you could ask to escalate therapy. I have a couple other thoughts on things that you know other places pharmacists can play a great role is?

Speaker 2:

you know? We all see the patients who have like three separate inhalers right, and so anytime we can ask to combine them into one inhaler, that can really be a saver for the patient, not only financially, because they're only paying one copay, but also just from an adherence sort of standpoint.

Speaker 1:

Yeah, absolutely, Inhaler fatigue I mean. And I wouldn't say they're not easy to use.

Speaker 2:

They're really not easy to use.

Speaker 1:

So I mean know a lot of issues occur because of, you know, misuse or poor use, and so anytime that we can help that, I think it's important.

Speaker 2:

The guidelines actually call that out too.

Speaker 1:

Like anytime you're following up with a patient, they want you to assess inhaler technique, and so that could certainly I was just going to say, like that's something else we should do as the pharmacy team is just make sure that technique we should not assume that the patient has been properly shown how to use exactly and you know there's so many different formulations and different devices.

Speaker 2:

The dry powdered inhalers can be really tricky for our patients with COPD because they're not always able to take that deep, forceful inhalation. Similarly, with the metered dose inhalers, sometimes they don't have good enough dexterity to be able to push, you know, and get their coordination of the breath in at the same time. If you've never tried it before, honestly I think it's more tricky than you think it is.

Speaker 1:

It is yeah for sure. Yeah, I've had the practice devices. You know that we used to teach the students and and yeah, I mean, I just felt like they're not super intuitive, so it really does.

Speaker 2:

It does and you know, if you have patients who are struggling, it's a good space where you could recommend a spacer or those vented holding chambers or whatever, just to help with that timing. Yeah.

Speaker 1:

Especially especially younger patients. If we're you know if we're talking about. Of course, mostly that would be asthma. But you know that is just that's a great place to really kind of interject as a pharmacist.

Speaker 2:

And then you know the newer soft mist inhalers too. Those are really tricky because you really got to assemble them and so just ensuring, like, have you used this inhaler before? If not, like, let me teach you how to do this, because it's really tricky to put these things together and to know the differences and all of that as well.

Speaker 1:

Yeah, yeah, I mentioned earlier that it's been a few years since I've practiced in a pharmacy site, but do they still have the ones where you take the capsule and put it in and then it? So, yeah, I remember having a patient that that actually would just swallow the capsules and they didn't understand that that wasn't, and then they were just like breathing in nothing because they just thought you like used it as like a tool to help you breathe. And again, the assumption was somebody at some point showed them how to use this and the realization was no one ever did.

Speaker 1:

The medication was not being received.

Speaker 2:

I had a patient once who came in with that same sort of inhaler where you put the capsule in the device and then you puncture it and you breathe it in. And so he had read the directions and it said it was supposed to make this high pitch sort of sound when you breathe in. And he was convinced that he was not getting a dose and convinced that it was not working correctly. And so I had him come in and show me how he did it. And it turns out he was doing it perfectly, but his hearing was such that he wasn't able to hear.

Speaker 1:

Yeah.

Speaker 2:

Yeah. So I thought it was really great that he, you know, took the initiative to say I don't think I'm doing this right. Will you observe me? Will you check this?

Speaker 1:

Yeah.

Speaker 2:

And you know, I think whenever we talk about adherence, we can't not talk about affordability of medications as well. A lot of these patients probably aren't on Medicare because, like we said, it's a progressive disease that often we add more medications as patients tend to age and so sometimes we're able to utilize Medicare Part B for some of the nebulizer solutions that can sometimes be more affordable for patients. So there are a variety of nebulizer solutions that are available now that kind of circumvent some of the Part D deductible in that Now, with the donut hole going away, that might be a little bit of a different story. In 2025, yeah, you might be able to use more of the Part D covered medications. So it'll be interesting to see how that landscape kind of changes in 2025 and beyond.

Speaker 1:

Definitely something for us as pharmacy teams to keep in the forefront of our minds, like just making sure that our patients are not passing up on their medication because of a copay. Like we need to make sure that they're getting the medications.

Speaker 2:

Yeah, or can we set them up with a patient assistance program? Is there a coupon? Is there anything else we can do to help out these patients, to make sure that they're able to afford them? Right, yeah.

Speaker 1:

Yeah, right, right. Yeah, that's great, you mentioned these a little bit, but maybe any additional barriers that you can think about as we try to implement just COPD management in general, not necessarily just because of the updates and the guidelines, but are there any barriers that we kind of need to be aware of or overcome?

Speaker 2:

Yeah, I think that just kind of a lack of awareness on how to treat COPD is huge. I feel like a lot of primary care providers have their like go-to inhaler that they use for anybody who struggles with breathing, whether it's asthma or COPD, and so just you know, having some awareness of which inhalers are actually for asthma and which ones are for COPD, I think is is just a good starting place and we already kind of talked about some of the cost concerns and adherence.

Speaker 2:

Most of the inhalers are only available as brand name and so it becomes it becomes challenging.

Speaker 1:

Yeah, yeah. What are some of the typical comorbidities that we see with COPD? Is there? Are there other things that typically go hand in hand with it, or other complications that lead to other medications and whatnot Like? Are there other things that we should be looking at and managing, other than just the inhalers and the labas and the lot you know like? What else should we be paying?

Speaker 2:

Yeah. So I think, um, tobacco use is a huge contributor to COPD, and so there are some patients, you know, that are still smoking and they um do develop COPD, and sometimes that's enough to get them to want to quit and sometimes they're like, oh, the damage is already done, why would I quit smoking at this point? But the literature really shows that smoking cessation at any point is beneficial, and so I think that's a point that pharmacists can really provide some education on and drive home, you know, maybe get them set up with a referral to somebody that can help with tobacco cessation. Or some states, you know, allow that prescriptive authority or whatever it might be in your state. So I think that's a huge space that we could lean into and help patients because it's going to help prevent that progression of the disease.

Speaker 1:

Yeah, that's great, and you'd mentioned that some patients do have combinations of COPD and asthma. Is that pretty common or is that a smaller amount of people?

Speaker 2:

I would say it's a smaller amount of people, people who have asthma that is not well-controlled. Sometimes it will progress to COPD. Or if you have patients with asthma who are also tobacco smokers, then oftentimes they will end up with both diseases. Yeah, but one does not necessarily correspond to having the other.

Speaker 1:

Lead to the other, right? Yeah, okay, that, I guess, is my question. Thanks for reading in between the lines and reading my mind on that one.

Speaker 2:

That's what I meant there's a couple of disease states that get tricky to manage with COPD. One of them is anxiety and because sometimes when patients feel anxious, they get that chest tightness and they feel like they have trouble breathing and then it's almost challenging for them to differentiate Is this my anxiety or is this my COPD? And so then they'll try to manage it with, like their rescue sort of inhalers and you know it may or may not help, but that can sometimes be triggering and you know, when they can't breathe and they feel anxious, and so it kind of becomes this like sick and similarly heart failure, like sometimes it's really hard for patients to determine is this like my heart failure or is this my COPD? That's making me feel like I have less energy and more short of breath and that sort of thing.

Speaker 1:

Yeah, especially or if they are in V-fib or something like that, where that already kind of is a pole on the body. I know that my mom knows immediately when she's knocked out of rhythm because she just she can't move, she can't get up, it's just exhausted. So, yeah, I could see where that could be blurred lines in between. You know what's actually going on or what's progressing. So it's good feedback. Okay, well, that's great. So if we are vigilant as pharmacists and we're looking out for these opportunities and we are interjecting on behalf of our patients, advocating for the proper therapy, for that combination therapy and you, and just trying to help patients make sure that they're seeing the right people, what are some of the benefits or outcomes that we would see from that? What can we expect to see?

Speaker 2:

Yeah, I think if we're really making those recommendations, educating everyone whether it's patients, prescribers, whatever, getting patients on that correct regimen for COPD, what we'll see is that, you know that decline in lung function that we see happening more exponentially in our COPD patients is going to slow and so we'll see less disease progression. We also will hopefully see less exacerbations for our patients. So anytime patients are having exacerbations, that typically leads to COPD progression, and so we're keeping them out of the hospitals, we're keeping them at home, we're keeping them happier and able to hopefully live more normal lives, delaying that need for oxygen therapy. All of those things can be really challenging for patients as COPD progresses and they just have to work so hard even just to breathe to do their daily tasks.

Speaker 2:

So I think that's really really the end goal with all of this.

Speaker 1:

Sure, yeah, so quality of life of the patient as well, as you know, basically healthcare dollars, because if you're looking at decrease in hospitalizations, then you know you're looking at saving saving money in the end. So, yeah, that's great. Well, this has all been wonderful. Like I said, the lead in 30 seconds was telling for me that I was going to learn a whole lot from this episode, and this has been very, very interesting and helpful. Is there anything on your list or agenda that you wanted to be sure that you share to our listeners? Before we kind of wrap things up, I want to be sure that I'm giving you a chance to make sure you've got all the good stuff out for us.

Speaker 2:

I feel like I've got pretty much everything out there. The only thing maybe I haven't pitched yet is that we all know that pharmacists play a huge role in vaccinations, and these are patient population. Oh, that's great, yeah, this patient population with a lung disease. There's so many vaccinations that we want to make sure that they're getting, whether it's the new RSV vaccines, the pneumococcal vaccines, the COVID, the influenza all of those lung diseases can be really beneficial for this patient population.

Speaker 1:

Yeah, that's another thing that pharmacy teams can do is make sure that we're asking the questions, checking the registries, seeing what they're due for, having the conversations if it's you know, if it's the pneumonia, and having the right recommendations and whatnot. So, yeah, that's great. And also, you know, our vaccine is still so new. I think there's a lot of misconception and a lot of confusion out there. So, really, education and guidance is essential.

Speaker 2:

For sure, and to that point, if you're giving them one vaccine, run that report. Find out what else they're due for. Find out if you can do everything else at the same time. They're already there, they're already ready for the vaccine, so I think that's a great call.

Speaker 1:

Yeah, that's a great point. Thanks for interjecting. That's huge. So, as a wrap up, I would like to ask my guests each week to just give me a summary like what's the game changer here? Where can we really make a difference as a pharmacy, as a pharmacist, and what are we looking at here? That's important.

Speaker 2:

Yeah, I think the biggest game changer here for COPD management is really trying to ensure that all of the patients are on that lab-a-lama combination therapy as one inhaler if possible, to really help prevent those exacerbations and help with those daily symptom management.

Speaker 1:

Yeah, and don't forget to counsel on the proper use of that inhaler. Yeah, for sure that's great. Well, that's all we have time for this week. Thanks again for joining me today, allison. This has been so informative and just great information as a pharmacist, so thank you so much. Of course, if you're a CE plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at ceimpactcom. And, as always, have a great week and keep learning. I can't wait to dig into another game-changing topic with you all next week.