Step down therapy in COPD

[Hernandez]

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http://www.nejm.org/doi/full/10.1056/NEJMe1409219

An interesting read, I more and more often find myself stopping meds in new referrals as much as I escalate therapy, anecdotally this mirrors my experience

 

[group_theory]

http://www.nejm.org/doi/full/10.1056/NEJMe1409219

An interesting read, I more and more often find myself stopping meds in new referrals as much as I escalate therapy, anecdotally this mirrors my experience

Interesting. The challenge sometimes is to convince patients that medications are unnecessary (for now).

I've seen three type of patients (with COPD) referred to me ...

The first is that the patient who doesn't have COPD. But the patient is an adult, who used to smoke at one point in their lives, and now they are short of breath. Instant COPD diagnosis that goes into the medical records (and gets copied into the past medical history forever). Never had PFTs. No imaging. And started on ICS+LABA and long-acting anticholinergics right away (without any relief). They're easy to convince to stop their meds. Depending on their underlying pathology, steroids may have helped (and thus the confusion with COPD/asthma)

The second is the early COPD patients with minimal symptoms (think of your Class A COPDers) who don't need the gauntlet thrown at them. I try to pare down their meds to what is necessary (but warn them that they may end up back on them in the future ... hey, it's the nature of the disease)

The third are those with bad symptoms (your Class D phenotype) already maxed out, and some PCP decided to put the patient on high dose steroids indefinitely before referring to pulm. Trying to get the patient off steroids is next to impossible if the patient believes that steroids helped.

I think oral steroids and inhaled steroids are used and prescribed so often that people often forget the downsides and side effects that these meds have (short and long term)

Still hesitant to use daily azithromycin until I know more about the long-term safety of its use.

 

[Hernandez]

You could use erythromycin but the studies I read were comparison to ICS meds, not in addition do, if ya have new data that'd be interesting for me to read as I had 1 guy right now that I'm tempted to escalate to symbicort/spiriva/daliresp/macrolide/hs bipap. I don't want to add long term steroids as I haven't seen them work and he has an exceeding rare collagen vascular disease with lots of bone issues. And I'm having a heck of a time to keep him out of the hospital.

I also saw my lady yesterday who was on 12mg dexamathazone a day and was told she'd die if she ever came off of it, that took me 6 months to get her convinced I was right and then to taper to off. She's off but complaining of fatigue...but she's been complaining about it since before my taper started....did I mention her fev1 was 83%?

 

[Hernandez]

I probably write more pulm rehab than meds, I wish I could convinced my hospital system to add 3 more programs scattered around my city and provide cheap or free transportation

 

[group_theory]

You could use erythromycin but the studies I read were comparison to ICS meds, not in addition do, if ya have new data that'd be interesting for me to read as I had 1 guy right now that I'm tempted to escalate to symbicort/spiriva/daliresp/macrolide/hs bipap. I don't want to add long term steroids as I haven't seen them work and he has an exceeding rare collagen vascular disease with lots of bone issues. And I'm having a heck of a time to keep him out of the hospital.

I also saw my lady yesterday who was on 12mg dexamathazone a day and was told she'd die if she ever came off of it, that took me 6 months to get her convinced I was right and then to taper to off. She's off but complaining of fatigue...but she's been complaining about it since before my taper started....did I mention her fev1 was 83%?

12mg of dexamethasone? Did she have neuro sarcoid with exacerbation? That's an insanely high dose. I've started chronic steroids on rare occasion on my end-stage COPD on oxygen, but more for palliation (and with the patient and family understanding that steroids will shorten lifespan and increase mortality). At that point, they just want symptom relief and want quality over quantity (plus usually their ages are in the 80s/90s, so they deserve quality over quantity). This is after I tried everything, including nutrition consult/depression screening/pulm rehab. I'm starting to get palliative care involved too, to help with symtoms (and sometimes to help with advance directive planning ... dont want my patients ending up in the icu)

Have you tried oral N-acetyl cysteine 600mg BID on your COPD patients yet?

 

[Hernandez]

Not yet for COPD as it's been too difficult to get due to shortages, prior to the last arm of panther I had a few IPF I have tried to get on it and only 1 could fill it, I may have to try prior to adding chronic 'roids since ya mention it. The frustrating thing about this case is he had been hospitalized 4 times in 2 months and tubed once and not only had they not consulted pulm, but they hadn't sent him home on any copd medications.


The steroid pt was billed as COPD, and the story was odd

 

[jdh71]

Whoa. Hold up. Calling these medications "unnecessary" I think is a BIG leap. The notion that not all COPDers need to be on 3 inhalers, including the very severe, didn't need a study. All the data to this point of any of the inhaled medications NEVER actually showed in a decrease in exacerbations or a decrease in the decline of FEV1. Inhalers have ALWAYS been about symptomatic treatment. God bless the NEJM I guess . . .

I treat my patients to symptoms and convenience. If a patient says they get no benefit from an inhaler, I don't continue it. Done. I only add daliresp for frequent exacerbators with lots of sputum, and since I trained with one of the authors of the azithro paper who thought it was all garbage (heh), I never use it. He liked NAC and suggested everyone buy it off of amazon not from a pharmaceutical company, without blinking, suggested trying to get the free shipping.

(look for that trial in a few years BTW)

 

[Hernandez]

Whoa. Hold up. Calling these medications "unnecessary" I think is a BIG leap. The notion that not all COPDers need to be on 3 inhalers, including the very severe, didn't need a study. All the data to this point of any of the inhaled medications NEVER actually showed in a decrease in exacerbations or a decrease in the decline of FEV1. Inhalers have ALWAYS been about symptomatic treatment. God bless the NEJM I guess . . .

Well...if they don't need them doesn't that define unnecessary?

I'm not calling BS but my shenanigan meter is going off that none of the inhalers decrease exacerbations

 

[jdh71]

Well...if they don't need them doesn't that define unnecessary?

I'm not calling BS but my shenanigan meter is going off that none of the inhalers decrease exacerbations

Not in my opinion. If they feel they need them to be symptomatically better I call that necessary.

The problem with exacerbations and studying them is you can't control for temp, allergens, or viruses in the community that I bet brings in a lot of noise.

But even if you could prove ZERO exacerbation benefit if patients feel better, then they are worth it. Plenty of medicine treats symptoms. I don't see why this would be any different.

 

[Hernandez]

We're basically saying the same thing and do the same but are being cantankerous since we're both don't necessarily buy the data. I do titrate to symptoms but I will titrate for exacerbations

 

[jdh71]

We're basically saying the same thing and do the same but are being cantankerous since we're both don't necessarily buy the data. I do titrate to symptoms but I will titrate for exacerbations

I think titrating to exacerbations is definitely reasonable on a case by case basis. I know you well enough to know you practice thoughtful medicine.