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Respiratory Articles of Interest

What’s new in the pharmacotherapy management in COPD?  CTS position statement: Pharmacotherapy in patients with COPD-an update

Bourbeau J, Bhutani M, Hernandez P, Marciniuk DD, Aaron SD, Balter M, et al. CTS position statement: Pharmacotherapy in patients with COPD-an update. Canadian Journal of Respiratory, Critical Care and Sleep Medicine. 2017; 1(4): 222-241.

Submitted by Shirley Quach

From the last Canadian Thoracic Society (CTS) COPD guideline update in 2008, new clinical evidence and pharmacotherapies have been challenging the treatments for COPD. The objective of this CTS position statement is to review the available pharmacotherapies and to provide clinical guidance in the treatment and management of stable COPD.

The new CTS statement elaborates on the following points:

1- Guidelines for choosing appropriate maintenance pharmacotherapies to help Improve symptoms, exercise tolerance, and health status in stable COPD

2- Guidelines for choosing appropriate pharmacotherapies for preventing and reducing the frequency of acute exacerbations in stable COPD

3- Guidelines to treating patients who have Asthma and COPD overlap (ACO)

The CTS position paper is advocating for personalized pharmacotherapy treatments compared to previous COPD guidelines. CTS is encouraging clinicians to prescribe therapies to patients with the intention to alleviate symptom burden, decrease the risk of exacerbations and improve quality of life, and to not simply treat the degree of airflow obstruction.

There is growing evidence to demonstrate improved clinical outcomes with combined inhaled therapies, and if required, “step up” therapies should be considered. Individuals with COPD should have maintenance therapy of LAMA or LABA monotherapy, and LAMA/LABA dual therapy should be prescribed if symptoms and exacerbations persist. ICS can be added if LAMA/LABA dual therapy is not effective in minimizing exacerbation frequency and symptom burden; however, there is no evidence to demonstrate ICS/LABA/LAMA triple therapy is superior than LABA/LAMA dual therapy. While “step down” of treatments should be exercised with caution, this can be considered and applied to patients who exhibit more risks than benefits in the prescribed therapy.

Severe Asthma CTS Position Statement 2017

Fitzgerald JM, Lemiere C, Lougheed MD, Ducharme FM, Dell SD, Ramsey C, et al. Recognition and management of severe asthma: A Canadian Thoracic Society position statement. Canadian Journal of Respiratory, Critical Care, and Sleep Medicine. 2017Feb;1(4):199–221.

Submitted by Priscila Robles

Severe asthma is defined as requiring treatment with high-dose inhaled corticosteroid (ICS) and a second controller for the previous year, or systemic corticosteroids for 50 per cent of the previous year to prevent it from becoming “uncontrolled”, or which remains “uncontrolled” despite this therapy. This Canadian Thoracic Society position statement clearly distinguishes severe asthma from uncontrolled asthma – the latter being mostly commonly due to inadequate asthma management. The role of new and emerging therapies in severe asthma and the identification of potential responders are discussed and a revised treatment algorithm is provided accordingly. Adherence to treatment, inhalation technique, domestic/work environment, co-morbidities, a written action plan and referral to educators/specialists should all be verified carefully before establishing a diagnosis of severe asthma. Individuals with confirmed severe asthma are phenotyped using total IgE, peripheral eosinophil count, sputum eosinophils and FeNO testing to inform add-on therapies: i) anti-IgE therapy to reduce asthma exacerbations in children (≥6 yrs) and adults who are sensitized to at least one perennial allergen and poorly controlled despite high doses of ICS and second controller therapy; ii) Anti-IL5 therapies for adults with severe eosinophilic asthma who experience recurrent asthma exacerbations despite optimal management; iii) addition of omalizumab for children and adolescents with poor control when therapy is stepped down; iv) addition of tiotropium bromide inhalation for individuals aged ≥ 12 yrs with severe asthma uncontrolled; v) macrolides considered independently to a specific phenotype. This position paper offers health-care practitioners an objective approach for the recognition and management of severe asthma in Canada.

Choosing wisely: The Canadian Thoracic Society’s list of six things that physicians and patients should question

Gupta S, Goodridge D, Pakhalé S, McIntyre K & Pendharkar SR. Choosing wisely: The Canadian Thoracic Society’s list of six things that physicians and patients should question, Canadian Journal of Respiratory, Critical Care and Sleep Medicine. 2017; 1(2): 54-61, DOI: 10.1080/24745332.2017.1331666

Submitted by Jane Lindsay

In an effort to help improve quality while reducing waste in healthcare, the Canadian Thoracic Society (CTS) is using the “Choosing Wisely” campaign. This initiative assists both patients and clinicians as they discuss options for care, with the goal of reducing unnecessary tests, treatments and referrals.
In order to generate their list of recommendations, the CTS appointed a 5-member Choosing Wisely Task Force, consisting of four respirologists and one nurse/PhD scientist from four cities across Alberta, Saskatchewan and Ontario. Their initial list used existing Canadian and US Choosing Wisely recommendations, Canadian Medical Association (CMA) Patient-Oriented Evidence that matters, and suggestions from CTS content experts. This initial list was reduced by voting members of the CTS and the Task Force in three electronic Delphi processes in online polls. Evidence reviews, which are explained in the article, were used to reduce the top ten recommendations to the “Choosing Wisely Top 6” list.
The six items on the list will probably not be surprises to ORCS members, but this will provide a useful tool during patient conversations. The list of six “don’ts” includes recommendations on the use (or not) of maintenance inhalers for stable COPD patients, CT screening for cancer in low-risk patients, CT and VQ scans to evaluate some patients for pulmonary embolus, antibiotics for adult cough, medications for asthma patients under six years old, and antibiotics during asthma exacerbation.
The authors acknowledge that creation of the current list is only the first step, and there will be challenges in the ‘de-implementation’ of several current practices. For example, in order to de-implement some treatments, items one and five call for an increase in the use of spirometry – the underuse of which is a much bigger problem in primary care than in respirology. ORCS members can hopefully act as change agents to help with the dissemination and implementation of these recommendations.

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