Dual bronchodilation is the new standard for the treatment of COPD, chronic obstructive pulmonary disease. Only the triple association reduces mortality. Therapies with a single inhaler are recommended. These are the main recommendations of the new Gold report (Global initiative on obstructive lung diseases), the most important document for the diagnosis, prevention and treatment of COPD, published these days and at the center of a meeting with the press promoted by GSK today in Verona.
“The objective of the document – explains Claudio Micheletto, UOC director of pulmonology at the Integrated University Hospital of Verona in his speech – is to improve the management of COPD which has a strong impact on the quality of life due to exacerbations and hospitalizations. Respiratory insufficiency is the second cause of hospitalization, first there is only decompensation”. Furthermore, COPD is the third leading cause of mortality in the world. A chronic respiratory disease characterized by persistent airflow limitation, it typically occurs in people over the age of 40 and predominantly in smokers or ex-smokers. It affects 380 million people in the world, 11.7% of the population. According to Istat data, in Italy the disease affects 5.6% of adults (about 3.5 million people) and is responsible for 55% of deaths from respiratory diseases.
First of all, the Gold – it was recalled during the event – referring to the results of the Emax study (Early MAXimization of brochodilatation for improving Copd stability) – to control the pathology it is necessary to start with double bronchodilatation (the association between Lama and Laba), a combination that becomes maintenance therapy. The picture must be modified in the event of the presence of more than 300 eosinophilic white blood cells in the blood, which suggests switching to triple therapy, i.e. adding the ICS, i.e. the corticosteroid, to the Laba-Lama. Compared to the past, the approach with only the Ics-Laba is no longer considered, or rather recommended.
In the new Gold report, “given the importance, priority was given to exacerbations over symptoms – argues Alberto Papi, professor of respiratory system diseases, University of Ferrara – An important review was made on which treatments to start and on which to continue. exosinophils in the blood, which achieves solid and important goals on the reduction of exacerbations and mortality”. Only the triple therapies demonstrate the reduction in the risk of mortality from COPD, as demonstrated by the Impact (fluticasone furoate/umeclidinium/vilanterol) and Ethos (budesonide/glycopyrronium/formoterol fumarate) studies, to which the recommendations dedicate specific paragraphs.
Compliance and consequently adherence have always been among the problems in chronic respiratory diseases, the experts highlighted. Both are somewhat daughters of the simplicity or otherwise of the treatments, bearing in mind that, although it is no longer a disease for old people, most of the patients are elderly and perhaps also suffer from other diseases that require daily pharmacological interventions. A 2017 Doxa research shows that only 62% of interviewees with COPD are treated regularly (or almost), 33% take drugs only during the acute phase and 5% only in an emergency.
“The relationship between oral inhalation therapy has some critical issues – underlines Claudio Cricelli, president of the Italian Society of General Medicine and Primary Care (Simg) – If we force 2-3 doses a day, a good percentage jumps”. In this regard, the Golds state that, precisely for this reason, doctors and specialists should take into consideration preconceived therapies compared to extemporaneous associations, i.e. therapies contained in a single inhaler. Specifically, the Golds refer to the results of the Impact (InforMing PAthway of COPD Treatment) and Intrepid (INvestigation of TRelegy Effectiveness: usual PractIce Design) studies which evaluated the efficacy of the triple fluticasone furoate/umeclidinium/vilanterol). Finally, the new recommendations focus attention on the risk of exacerbations and worsening, which can be countered with tailor-made treatments to be studied on a case-by-case basis and with therapy to be optimized if inadequate control of the disease is found.