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The Global Initiative for Chronic Obstructive Lung Disease, or GOLD, is the world’s preeminent COPD research and advocacy organization. Founded in 1997 in collaboration with the U.S. National Institutes of Health and the World Health Organization, one of GOLD’s stated aims is to “improve prevention and treatment of this lung disease.”
In its 2023 global strategy report, GOLD changed its definition of COPD—which many in the profession viewed as overdue. Specifically, the new definition emphasized the heterogeneity of COPD in terms of its underlying drivers and long-term disease course.
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“If you look at the new GOLD guidelines, they’re really acknowledging that there’s more of an inflammatory component to COPD than we initially thought,” says Dr. Laren Tan, a pulmonary disease and critical care specialist and chair of the Department of Medicine at Loma Linda University Health in California.
Tan says the recognition that COPD can take unconventional forms is crucial to tailoring appropriate care to the individual patient. “We’re now approaching COPD in terms of trying to identify subgroups of patients that have this underlying inflammatory state,” he says. “If we don’t uncover this inflammatory component, that can lead to worse outcomes.”
Here, Tan and other experts in the field describe how this new understanding of inflammation is informing treatment. And it’s just one of several recent advances in COPD care and management. From innovative new lung valves to refinements in the deployment of inhaled therapies and vaccines, the landscape of COPD care and treatment is changing.
The newest drug therapies
Arguably the most buzzed about advancement in the COPD treatment landscape is the emergence of new biologic therapies, says Dr. Meilan Han, a professor of medicine in the Division of Pulmonary and Critical Care at the University of Michigan. Biologics are injected medications derived from living cells or other biologic material that are able “to target very specific immune pathways,” Han explains.
Essentially, these drugs are intended to narrowly shift or block the operation of the immune system, thereby switching off or moderating the types of inflammation or other immune reactions that drive some COPD exacerbations while simultaneously leaving the remainder of the immune system unaffected. The drugs are already used to treat related pulmonary conditions, like asthma, and there’s reason to believe they’re about to enter the COPD arena.
“The exciting news is that there is a drug that looks like it will work for COPD, and that may soon have [U.S. Food and Drug Administration] approval,” Han says. That medication, dupilumab, is already approved for the treatment of asthma. In July 2023, a study published in the New England Journal of Medicine found that patients with so-called Type 2 inflammation—defined by the elevated presence of blood eosinophils—benefited from dupilumab. The patients experienced “fewer exacerbations, better lung function and quality of life, and less severe respiratory symptoms than those who received placebo,” the study found.
“What we’d seen in the last few years prior to this was that companies were fleeing respiratory drug development because a lot of studies had failed,” Han explains. “Dupilumab is just one drug, but it opens up the door for a lot more research and exploration of biologics for the treatment of COPD.” She notes that there are multiple trials examining additional biologics that target new pathways. “I’m hoping this is just the tip of the iceberg, and soon we’ll have many more new therapies,” she adds.
While biologics are garnering the most attention, experts say that smaller, more incremental improvements in care are having a greater impact on the day-to-day lives of COPD patients.
For example, phosphodiesterase inhibitors have long been used to help treat the mucous production and accumulation that so many COPD patients experience, Tan says. “The new phosphodiesterase inhibitors help relax airway smooth muscle and also help to clear out mucus from airways,” he says. “But patients take this as a tablet, which unfortunately comes with a lot of side effects, such as GI issues.” To prevent these side effects and improve the drug’s efficacy, researchers have looked into the development of inhalable forms of these drugs, and Tan says there’s promising data that these work.
Staying in the inhaler space, one of the greatest challenges in COPD care—and, for that matter, in the care of asthma and other lung conditions—is the problem of poor patient adherence to medications. Inhalers are often a mainstay of symptom management, but it can be a struggle for people to use an inhaler consistently, especially when treatment involves more than one type of inhaled drug.
This problem of adherence led to the development of combination inhalers—a single device that allows a patient to take two or even three medications simultaneously. “They’ve taken all these inhalers and put them into one device,” Han says. “This makes it easier for patients to take their medications, and this has led to a reduced frequency of exacerbations.”
In parallel with the emergence of combination inhalers, research has revealed that, for some COPD patients, the blend of three inhaled medicines may be superior to the old two-drug approach. “For most patients, we prescribe two long-acting bronchodilators,” says Dr. Peter Barnes, a professor of thoracic medicine at the National Heart and Lung Institute in the U.K. These are a long-acting muscarinic antagonist, or LAMA, coupled with a long-acting β2-agonist, or LABA. While this LABA/LAMA combination is nothing new, Barnes says that adding a third medicine—an inhaled corticosteroid—has proven helpful in patients with high blood levels of eosinophils. “These three can now be combined in single inhaler, called a triple inhaler,” he says.
Plus, some of the first research studies on the long-term benefits of these triple inhalers have found that they may reduce mortality among patients who use them. “When used appropriately in combination, these drugs can save lives,” Han says.
Read More: Severe Asthma Patients on Ways Their Doctors Could Improve Treatment
Valves, telemedicine, and other advances
Lung volume reduction surgery, or LVRS, is one of the most common surgical procedures for the treatment of COPD. The procedure, which has been around since the 1950s, involves the removal of the most diseased parts of lung tissue in order to allow better, less-restricted lung expansion during breathing. “When you take that diseased part out, that helps to restore the lung’s natural mechanics,” Han says.
But this surgery comes with downsides. “It’s a major surgery with a long recovery time, and the risk for complications is high,” Tan says. These complications include unintended air leakages, pneumonia, and heart issues such as arrhythmias.
In just the past few years, a new and milder intervention has emerged. Two different companies have developed valves that can be placed in the airway using a minimally invasive procedure, and that allow trapped air to escape the damaged lung. “These are essentially a one-way valve that allows air to go out of the affected areas of the lungs,” Tan explains. “This helps improve ventilation and breathlessness.” The procedure, known as bronchoscopic lung volume reduction, mimics the effects of the older surgery, but is reversable.
Aside from new drugs and surgical procedures, vaccines are another area that should lead to better symptom management. “With COPD, a lot of common viruses—things like respiratory viruses—can contribute to periodic flare-ups or exacerbations,” Han says. Vaccines can help prevent these viral infections, and more are becoming available all the time. “The ramp-up of vaccine development we saw during the pandemic—I’m hopeful we’ll continue to see new vaccines for things like rhinovirus that have a major impact on COPD,” she says.
Experts say there have also been helpful advances in the way COPD patients and their care providers interact.
“Pulmonary rehab doesn’t get much buzz, but we know it’s critical for a patient’s daily functioning,” Tan says. Pulmonary rehab often involves group education courses that teach people with COPD how to adjust their lifestyles—for example, by incorporating safe forms of exercise, or learning to prepare healthier meals—in order to improve their symptoms and functionality.
Unfortunately, reimbursement and insurance coverage for pulmonary rehab is poor. Plus, attending the group sessions can be difficult or inconvenient for people who don’t live close to their center of care. “But during the pandemic, we found that we can offer pulmonary rehab remotely through telehealth, and I think that’s been a gamechanger,” Tan says. While many of those pandemic-era telehealth programs have since been suspended, they acted as a proof-of-concept—a demonstration that pulmonary rehab courses can be offered virtually—that Tan hopes will eventually increase access and reduce costs for people with COPD.
Smoking cessation is another area that has witnessed some noteworthy advancements, Tan says. A majority of COPD patients are current or former smokers, and a lot have trouble quitting despite the help of medications and patches or other nicotine-replacement aids. “Now we’re starting to see people using an AI-powered app to help them quit,” he says.
Earlier this year, the Fred Hutchinson Cancer Center launched a free QuitBot AI app. The app offers personalized smoking cessation support—answering questions and providing evidence-based pre- and post-quit-date education materials—that can help people stick with it.
Meanwhile, researchers at Johns Hopkins University have found that combining psychedelics with cognitive behavioral treatments can lead to remarkable cessation rates. One study found that 80% of people were able to stay cigarette-free six months after the treatment—an unheard-of success rate for smoking cessation therapies.
Read More: How Alternative Medicine Can Help People With Asthma
What’s next?
In many branches of medicine, researchers and providers have turned their attention to better, more comprehensive diagnostics. With the help of advanced genetic testing, blood analyses, and other cutting-edge assessment tools, doctors can get a clearer picture of a patient’s underlying disease state, which can guide them toward the most efficacious and precise treatments—and, as a result, improving outcomes and reducing side-effects or other quality-of-life challenges.
This, experts say, is where COPD care is headed. “We know now there are multiple subtypes of COPD—that the inflammatory sub-profile differs from patient to patient,” Tan says. “But the inflammatory process is extremely complex.” It will take time to map the different inflammatory pathways and processes at play, and years of work to identify or develop new medicines that treat those specific instigators of inflammation. But all of this is underway. And, as the latest research on biologics suggests, this form of precision medicine is going to be part of the COPD conversation for a long time to come.
“I’ve been doing this for 20 years, and this is the first time I feel like we’re at an inflection point where I’m anticipating a lot of new therapies within the next five years,” Han says.
For people with COPD—and their care providers—the future looks bright.
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For people with COPD—and their care providers—the future looks bright.
Uncategorized, freelance
Health – TIME
