Pharmacologic Treatment Models for COPD

Pharmacologic Therapy

In addition to lifestyle change and behavior modifications, pharmacological treatment can help patients manage their COPD and avoid or mitigate exacerbations. These treatments do not reverse or slow lung function decline, but they can help patients breathe easier by controlling their symptoms. Central to a COPD treatment regimen, bronchodilators ease bronchial obstruction and airflow limitations to improve airflow in and out of the lungs. Most bronchodilators are taken using a device called an inhaler. Long-acting bronchodilators, such as beta-agonists and anticholinergics, alleviate long-term symptoms and help patients control their COPD overall. Fast-acting treatments, commonly known as rescue medications, are available to rapidly alleviate airflow limitations in situations of acute lung stress; however, the effects only last for a few hours. Leading respiratory and pulmonary medical associations offer different levels of recommendations regarding bronchodilator use for COPD patients with varying levels of lung function, with stronger recommendations for use among patients with weaker lung function.

Oxygen Therapy

In addition to medications, primary care providers may prescribe supplemental oxygen to COPD patients. This is often most useful for patients with severe resting hypoxemia, particularly low levels of oxygen in the blood. There is limited research on the long-term benefits of supplemental oxygen for individuals with moderate-to-low resting hypoxemia. Different types of devices deliver oxygen, such as continuous oxygen or intermittent pulse dose oxygen.

The following organizations offer more detailed treatment recommendations and guidelines:

• BMJ Best Practice treatment algorithm
• Global Initiative for Chronic Obstructive Lung Disease: GOLD global strategy report

Examples of Pharmacologic Treatment Models

• Through Cary Medical Center, the Better Breathing, Better Living project for the Maine Rural Health Collaborative is implementing a variety of COPD efforts including but not limited to the Centers for Disease Control and Prevention's Tips From Former Smokers campaign, a “Better Breathing Club” support group, and remote patient monitoring with medication therapy management and counseling support through videoconferencing technology.
• Mercy Medical Center's COPD Inpatient Navigator Program uses patient navigators to help improve COPD patient readmission rates. Services include smoking cessation education, medication reconciliation and education, and oxygen needs screening among others.
• Ohio Northern University's HealthWise Mobile Health Clinic uses health professions students in an innovative mobile clinic model to deliver educational outreach and healthcare services in rural Hardin County, Ohio. The mobile clinic offers services 2-3 times each week at a variety of locations in the county, including churches, schools, and other gathering spaces. The program is using health professions students in order to address local barriers related to health professional shortages. Services include smoking cessation education, medication reconciliation, and patient navigation assistance.

Considerations for Implementation

Patients with limited incomes may not be able to afford medications, especially if they are prescribed a combination of pharmacologic therapies. This presents additional treatment barriers in rural communities, which generally report higher rates of poverty than the nation as a whole. Many rural programs rely on the 340B Drug Pricing Program to help their COPD patients afford their medications. This federal program requires drug manufacturers to offer outpatient medications to qualifying entities like healthcare centers and hospitals at a reduced price. Rural COPD programs have also found the national nonprofit NeedyMeds to be a useful resource in helping patients obtain additional funds for medications and other healthcare costs.

A 2017 analysis of nationwide Medicare Part D plans found that although COPD inhalers were almost always covered, many plans still had high out-of-pocket costs. The average out-of-pocket costs ranged from $30 to $105 per inhaler, depending on the type of inhaler. Patients with moderate to severe COPD may need up to three inhalers per month.

In addition to the high costs associated with inhalers, the devices may be confusing and difficult to use. Inhaler designs vary across medication type and pharmaceutical company, so there is no standardized method for using the devices. This can lead to issues with medication adherence if patients (and sometimes healthcare providers) do not know exactly how their device should function. Use of training tools may assist in demonstrating proper inhaler technique. For example, research shows the use of the In-Check DIAL has led to significant improvements in asthma care and control. Healthcare providers may consider using a teach-back method as an effective way to ensure that patients understand instructions on how to use specific medications.

Patients with COPD often have comorbidities that also require medication regimens. Not only does this add a cost burden, but medication management may become an issue as patients attempt to manage a complex regimen of medications. One potential solution is incorporating the unique role pharmacists often play in patient management and care. In rural communities, it may be easier for a patient to access a pharmacist than another healthcare provider. Pharmacists may have more time to spend with a person with COPD and are often aware of the different types of medications they may be taking.

There are also challenges associated with delivering supplemental oxygen. The units in which supplemental oxygen is prescribed by a physician does not always match the units of oxygen that are delivered by devices. It can also be difficult to manage the supplemental oxygen supply chain across long distances. Oxygen cylinders are transported directly to patients' homes, so there may be limited delivery availability in rural communities.

Program Clearinghouse Examples

• Better Breathing, Better Living
• Multidisciplinary Rural Mobile Clinic Using Student Healthcare Professionals

Resources to Learn More

COPD 101 Educational Video Series
Tutorial/Training
A collection of educational videos about COPD including the physical limitations and injury caused by COPD, resources on COPD screening and disease management, and training on the proper usage of various types of inhalers.
Organization(s): COPD Foundation

Optimizing Home Oxygen Therapy: An Official American Thoracic Society Workshop Report
Document
Defines optimal home oxygen therapy, identifies key barriers to accessing oxygen therapy at home including in rural communities, and discusses potential strategies and solutions addressing these barriers.
Author(s): Jacobs, S., Lederer, D., Garvey, C., Hernandez, C., Lindell, K., McLaughlin, S., Schneidman, A., Casaburi, R., Chang, V., Cosgrove, G., & Devitt, L.
Citation:Annals of the American Thoracic Society, 15(12)
Date: 12/2018

Oxygen Therapy
Website
An overview of oxygen therapy with information about getting started with different oxygen delivery devices, using oxygen safely, and helping patients with chronic respiratory conditions like COPD.
Organization(s): American Lung Association