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Australian Journal of Pharmacy : May 2008
professIonal feATure | resPirATory cAre because you can slow the progress of the condition and improve patient quality of life through appropriate management. COPD, unchecked, can have a significant impact on ability to complete even the simplest of tasks. At the severe end of COPD, just tying up shoelaces can be difficult,’ she said. Better management Dr Christine Jenkins, senior staff specialist in thoracic medicine at Concord Hospital, Sydney said that although there are no new medications for COPD, clinicians are now moving away from drugs as the sole platform for treatment. Current treatment strategies are all about better COPD management, Dr Jenkins told the AJP. ‘Being more proactive and focused on early diagnosis and early institution of treatment incorporating supervised exercise, rather than just treating with drugs. ‘While drugs will always be a crucial part of COPD management they are not the only part. Drugs give good symptomatic benefit, improve quality of life and reduce exacerbations. Patients, however, remain symptomatic despite these benefits.’ Without appropriate exercise smoking is the biggest cause of copD, with approximately 85% of copD in australia being linked to smoking history patients become ‘de-conditioned.’ And a vicious cycle begins, with breathlessness curtailing further exercise with associated muscle loss and, due to weakness, exercise begins even less likely. ‘For many patients COPD is not just a lung disease it is a systemic disease with a range of manifestations. Apart from muscle-wasting, patients can have high C-reactive protein (CRP) levels indicating inflammation. There is a tendency to lose weight even though these patients may be eating adequately. ‘We know appropriate levels of supervised exercise keeps COPD patients independent for far longer. Nothing will retrieve lung function but patients can maintain mobility, be active socially and improve mood. Things accumulate in a negative way if mobility is not maintained with a structured exercise program.’ Dr Jenkins said randomised trials show, no matter how little the exercise even walking 150 metres or improving arm strength can have real value in the range of daily activities. She added that access to a supervised exercise regime may be difficult for some patients. ‘Often GPs do not refer to a physiotherapist and this is because the patient has not been diagnosed with COPD. They mention breathlessness which is often attributed to age or being overweight. COPD is under-diagnosed. Identifying the disease can be done in general practice by taking a good clinical history and arranging spirometry. Immunisation against flu and pneumococcal is important. Dr Jenkins said there is also good evidence supporting early intervention with steroids and antibiotics to help reduce exacerbation and enhance recovery time. ‘Distinguishing a COPD patient from a normal patient is critical. We don’t encourage prescribing antibiotics in otherwise healthy patients with acute bronchitis, but patients with COPD need antibiotics promptly.’ Dr Jenkins said there is a high prevalence of airways disease in the community. ‘Many asthmatics are smokers and go on to develop COPD. She said there is a link between asthma and COPD but not a strong one. ‘And it may be important to distinguish between the two, although this is a topic of some debate at present. Unquestionably, patients can have both diseases and, unquestionably, people can have COPD that can be misdiagnosed as asthma or vice versa.’ ImprovIng outcomes Kenneth Chapman is professor of medicine at the University of Toronto, Ontario, Canada. He said there is a growing recognition that clinicians could improve treatment outcomes for COPD patients by combining therapies. Professor Chapman was visiting Australia for the annual meeting of the Thoracic Society of Australia and New Zealand. He said a decade ago the COPD patient would receive a puffer, or short-acting bronchodilator. Fast forward 10 years and many patients in Canada and Australia are still receiving ‘small doses of therapy’. These were short-acting brochodilators, with the urgent treatment of antibiotics and steroids when they became very sick. For the first time in 2007/2008 there has been a reduction in COPD mortality and it comes from a more comprehensive approach to treatment. It involves giving patients a combination therapy of seretide and tiatropium as opposed to relying on just one drug, Professor Chapman told the AJP. ‘We are prescribing longer-acting agents that work preventively, so COPD patients are more free of symptoms, less disabled and out of hospital emergency rooms. It is not so much new tools but using the available tools in a timely and comprehensive fashion. ‘We have seen in the last 10, or 15 years, a growing recognition that we are able to alter important clinical events like hospitalisations and mortality outcomes. COPD is a disease, not just with high day-to-day disability, but also high mortality. Professor Chapman said the demographics of COPD are changing; with more women in Canada and the US have the disease than men. ‘There are a number of reasons. One is that, at the beginning of the 20th century, it was rare for women to smoke. By the middle of the 20th century it became more common so women caught up to men in terms of their exposure. We know that women The AusTrAliAn journAl of PhArmAcy vol.89 mAy 2008 43