- COPD affects more than 1 in 20 Australians aged over 45, and is the fifth leading cause of death in Australia.
- While COPD is incurable, it is possible to treat symptoms, slow progression and prevent exacerbations with appropriate care.
- The NPS Medicinewise COPD program aims to improve the quality of life of Australians with COPD through improved medicines management in primary care.
- The three key areas for improvement are: accurate diagnosis and assessment of severity, stepwise management using Australian COPD-X Guidelines, and improvement of inhaler technique and adherence.
Improving quality of life
The NPS Medicinewise COPD program aims to improve the quality of life of Australians with COPD through improved medicines management in primary care.
Lung Foundation Australia estimates that COPD affects over 1.4 million Australians.1 More than 1 in 20 Australians aged 45 and over have COPD, based on self-reported data.2 Aboriginal and Torres Strait Islander people are more than twice as likely to report having COPD.2
In 2013, COPD was the fifth leading cause of death in Australia, and it ranks fourth in terms of burden of disease.2,3
The overall goal of the NPS COPD program is to improve the quality of life for Australians with COPD through improved medicines management in primary care.
There are three key areas for improvement:
- Accurate diagnosis and assessment of severity
- Stepwise management using Australian COPD-X Guidelines
- Inhaler technique and adherence
Accurate diagnosis and assessment of severity
Australian research shows that symptom-based diagnosis of COPD in primary care is unreliable, especially if patients are overweight,6 and that asthma may not be clearly excluded.7 Although both conditions have similar symptoms,8,9 and can be comorbid, it is important to differentiate between COPD and asthma because they require different therapeutic strategies.9 Some patients may have features of both asthma and COPD, known as ACOS (asthma–COPD overlap syndrome).
COPD is commonly unconfirmed or overdiagnosed – as many as two-thirds of people given the diagnosis and prescribed an inhaler have not had a spirometry test.10,11 A substantial proportion of patients clinically identified by GPs as having COPD do not have the condition based on spirometric criteria.12
In addition to misdiagnosis, data suggest that GPs are starting some patients with COPD on medicines inappropriate to the severity of their disease.13,14
The importance of confirming both the diagnosis and the severity of COPD
Rates of spirometry use are growing but there is still potential underuse of spirometry by GPs in the area of confirmation of diagnoses of COPD. When spirometry is performed, it is sometimes done sub-optimally.15
Spirometry, together with typical symptoms and exacerbations, is the most effective way of determining the severity of COPD.8 A major advantage of spirometry is that it can detect lung volume changes even before symptoms of disease become apparent. Thus, it can confirm the presence of COPD even in mild or moderate stages.16
Early diagnosis and appropriate treatment of COPD according to severity of symptoms can help patients avoid adverse outcomes and hospitalisations,17 and reduce the burden of disease.18 Individuals diagnosed with early stage COPD are potential candidates for interventions designed to prevent progression of the disease (stopping smoking).19
After a diagnosis is confirmed it can be communicated to patients – withholding or delaying a diagnosis can result in missed opportunities for slowing the progression of disease.20
Stepwise management using Lung Foundation resources
Lack of adherence to guidelines for both diagnosis and management of COPD is a widespread problem, resulting in increased risk to patients.21,22
Data suggest that GPs are starting some COPD patients on fixed-dose combinations of inhaled corticosteroids (ICS), long-acting beta-2 agonist (LABA) and long-acting muscarinic agonist (LAMA), ie, ICS + LABA, or LAMA + LABA (with or without ICS).23 This suggests that these patients may not have been prescribed medicines that are appropriate to the level of severity of their illness. A small number of patients may also be exposed to unsafe medicine use practices, including double dosing and the use of regimens that include concomitant use of a SAMA and a LAMA.
There is substantial evidence for adverse effects from the use of ICS in patients with COPD, most notably severe pneumonia resulting in excess deaths.24 It is therefore important to limit the use of ICS + LABA fixed-dose combinations to the minority of patients with COPD who might benefit, such as those with frequent exacerbations and with an FEV1 < 50% predicted. The benefits of the antimuscarinic agents are known to come at the cost of increased side effects, such as dry mouth and tremors.8 Stepwise management of COPD, following the COPD-X Concise Guide for Primary Care,4 can form part of a tailored strategy for individual patients, and help avoid adverse outcomes associated with incorrect prescribing or misuse.
Inhaler technique and adherence
COPD management is sub-optimal in some patients due to poor inhaler technique, incorrect prescribing of medicines, and high rates of non-adherence to medicines.25,26 Poor inhaler technique is associated with reduced control, and worse COPD outcomes.27
A number of new agents for COPD have become available for the treatment of COPD in recent years. These agents are delivered in a range of devices that work differently and need to be matched appropriately to each patient. But it is clear that up to 90% of patients don’t use their devices correctly and therefore aren’t receiving the dose they should.28 By some estimates, between 28% and 68% of patients do not use metered-dose inhalers or powder inhalers well enough to benefit from the prescribed medication.29
GPs may not regularly check and demonstrate inhaler technique or check adherence for various reasons such as time pressures,30 However, checking inhaler technique is not solely the domain of the GP – a practice nurse or pharmacist can assist.28
Consumers are both intentionally and unintentionally non-adherent to their COPD medicines.27 Prevalence estimates of unintentional non-adherence vary considerably, but are known to be very high in COPD, perhaps due to the older age cohort of patients with this illness.27 This is particularly an issue in patients over 65 years of age with polypharmacy.27
Inhaled bronchodilators continue to be the mainstay of drug therapy in COPD. However, drug therapy is reliant on the effectiveness of both the inhaled medicine and the delivery device. Options can be tailored to meet patients’ needs with careful selection of the inhaled medication and the device used for its delivery – correct use of the inhaler by the patient must be ensured.
Download a checklist for reviewing and teaching correct technique for a range of inhaler devices currently available.
- Toelle B, Xuan W, Bird T, et al. Respiratory symptoms and illness in older Australians: the Burden of Obstructive Lung Disease (BOLD) study. Med J Aust 2013;198:144-8. [PubMed].
- Australian Institute of Health and Welfare. COPD — chronic obstructive pulmonary disease. AIHW, 2016. [Online] (accessed 30 November 2016).
- Australian Institute of Health and Welfare. Australian Burden of Disease Study Impact and causes of illness and death in Australia 2011. Canberra: AIHW, 2016.
- Lung Foundation Australia. Stepwise Management of Stable COPD. Lung Foundation Australia. [Online] (accessed 16 December 2016).
- Altose MD. Approaches to slowing the progression of COPD. Curr Opin Pulm Med 2003;9:125-30. [PubMed].
- Walters JA, Walters EH, Nelson M, et al. Factors associated with misdiagnosis of COPD in primary care. Prim Care Respir J 2011;20:396. [PubMed].
- Family Medicine Research Centre. SAND abstract No. 182 from the BEACH program: Chronic obstructive pulmonary disease (COPD) in general practice patients (2). Sydney: University of Sydney, 2012. [Online] (accessed 25 January 2016).
- Yang I, Dabscheck E, George J, et al. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease v2.47. Milton QLD: Lung Foundation Australia, 2016. [Online] (accessed October 2016).
- Han MK, Kim MG, Mardon R, et al. Spirometry utilization for COPD: how do we measure up? Chest 2007;132:403-9. [PubMed].
- Lee TA, Bartle B, Weiss KB. Spirometry use in clinical practice following diagnosis of COPD. Chest 2006;129:1509-15. [PubMed].
- Zwar NA, Marks GB, Hermiz O, et al. Predictors of accuracy of diagnosis of chronic obstructive pulmonary disease in general practice. Med J Aust 2011;195:168-71. [PubMed].
- Family Medicine Research Centre. SAND abstract No. 214 from the BEACH program: COPD prevalence, severity and management in general practice patients – 2013. Sydney: University of Sydney, 2013. [Online](accessed 25 January 2016).
- Simeone JC, Luthra R, Kaila S, et al. Initiation of triple therapy maintenance treatment among patients with COPD in the US. Int J Chron Obstruct Pulmon Dis 2016;12:73-83. [PubMed].
- Eaton T, Withy S, Garrett JE, et al. Spirometry in primary care practice: the importance of quality assurance and the impact of spirometry workshops. Chest 1999;116:416-23. [PubMed].
- Mehta V, Desai N, Patel S. When Pulmonary Function Test is Available, Should we Wait for the COPD Symptoms to Develop? J Clin Diagn Res 2016;10:OE08-OE12. [PubMed].
- Mannino DM, Thorn D, Swensen A, et al. Prevalence and outcomes of diabetes, hypertension and cardiovascular disease in COPD. Eur Respir J 2008;32:962-9. [PubMed].
- Barthwal M, Singh S. Early detection of chronic obstructive pulmonary disease in asymptomatic smokers using spirometry. J Assoc Physicians India 2014;62:238-42. [PubMed].
- Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA 1994;272:1497-505. [PubMed].
- Walters JA, Hansen EC, Walters EH, et al. Under-diagnosis of chronic obstructive pulmonary disease: a qualitative study in primary care. Respir Med 2008;102:738-43. [PubMed].
- Braido F, Chrystyn H, Baiardini I, et al. “Trying, But Failing”—The Role of Inhaler Technique and Mode of Delivery in Respiratory Medication Adherence. J Allergy Clin Immunol Pract 2016;4:823-32. [PubMed].
- Brusselle G, Price D, Gruffydd-Jones K, et al. The inevitable drift to triple therapy in COPD: an analysis of prescribing pathways in the UK. Int J Chron Obstruct Pulmon Dis 2015;10:2207. [PubMed].
- Pharmaceutical Benefits Scheme. Post-market Review of Chronic Obstructive Pulmonary Disease (COPD) Medicines. Canberra: Department of Health, 2016. [Online] (accessed 19 January 2017).
- Ernst P, Saad N, Suissa S. Inhaled corticosteroids in COPD: the clinical evidence. Eur Respir J 2014. [PubMed].
- Restrepo RD, Alvarez MT, Wittnebel LD, et al. Medication adherence issues in patients treated for COPD. Int J Chron Obstruct Pulmon Dis 2008;3:371-84. [PubMed].
- Dudvarski IA, Zugic V, Zvezdin B, et al. Influence of inhaler technique on asthma and COPD control: a multicenter experience. Int J Chron Obstruct Pulmon Dis 2016;11:2509-17. [PubMed].
- Sanduzzi A, Balbo P, Candoli P, et al. COPD: adherence to therapy. Multidiscip Respir Med 2014;9:60. [PubMed].
- Lung Foundation Australia. COPD-X Concise Guide for Primary Care, 2016. [Online] (accessed 18 August 2016).
- Fink JB, Rubin BK. Problems with inhaler use: a call for improved clinician and patient education. Respiratory care 2005;50:1360–75. [PubMed].
- Plaza V, Sanchis J, Roura P, et al. Physicians' knowledge of inhaler devices and inhalation techniques remains poor in Spain. J Aerosol Med Pulm Drug Deliv 2012;25:16–22. [PubMed].