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non: [00:00:00] You are listening to the ATS Breathe Easy podcast brought to you by the American Thoracic Society.
Amy: Well, welcome everyone. My name is Amy
Attaway. I am here with ATS Breathe Easy podcast. I'm one of your hosts. I'm back again with Dr. Antonio Anzueto. So we had a coup, episode a couple weeks back about nebulizers in COPD, and given he's the expert on all things COPD, we thought it'd [00:01:00] be great to have another conversation with him about controller medications in COPD.
Just to give some background, so Dr. Anto, he is professor of medicine at University of Texas Health Science Center and the chief of pulmonary for the South Texas Veterans Healthcare System, and also on the gold science Committee and has helped organize the gold guidelines, many iterations. So I think we could start.
Maybe in discussing like how we define controller medications and COPD versus short acting agents.
Antonio: thank you Amy. Thank you for the ATS for invite me to participate, in this activity. certainly one of the important issue is, and the difference between medications. short-acting bronchodilators by history was the first medication that became available.
Then we start getting the [00:02:00] long-acting bronchodilators and they become what we call now controllers because they not only are non-acting, you have to take it most of them once a day or twice a day. Their efficacy results in sustain improvement in lung function. Improves the patient's quality of life. So I can tell Mr.
Johnson, Hey Mr. Johnson, your lung function improved by 150 mls. And guess what? You're going to feel better. You're gonna be able to do more. Furthermore has been shown to decrease exacerbations. So controllers has become the mainstream, therapy for the treatment of COPD due to all these effects that it has, and we can call it today.
The controllers changed the natural history of the disease, changed the progression of the disease.
Amy: So thank you. That's a great point. So you've kind of seen [00:03:00] the history, you've kind of seen how we've moved from the short-acting agents to the long-acting agents and how much better seen all these studies that show how much better patients do and have, improvements in lung function and reduced exacerbations.
Why do you think we still have this issue? Like what are some of the barriers to getting controller medications versus the short acting agents?
Antonio: I think they're very different issues. One is, a lot of patients is the lack of diagnosis. So they're a little short of breath. They're not sure what's going on.
They haven't had a diagnosis made, they haven't had spirometry. That is the only way we can make a diagnosis of COPD in 2025. and then so prescribers will provide them the medication and the reason SABAs available over a counter. That's an important issue, have to take into consideration that the patient may feel short of breath and go to the [00:04:00] pharmacist, oh, this inhaler that you can take that is a SABA.
And, and they, and they take that and the more than they take those medications, one, they are not impacting the disease. So the disease will continue to progress. And I had patients say, well, I've been using. Salbutamol for the last five years and still more short of breath. And I tell them, listen, I'm sorry to tell you that, but Salbutamol and the short acting bronchodilators doesn't do anything for the disease.
It is like you having a hole in your tire and you going for gas station to gas station to put in air. You're not solving the problem. And that tires eventually it's gonna completely give up. So the, the, also the short-acting bronchodilators, if you use it, regular, several times a day. individuals who are in their sixties, their seventies, they have other concomitant conditions like having cardiovascular disease increases the [00:05:00] risk of having cardiac arrhythmias.
And I have seen patients. That, have these intractable atrial fibrillations that they're going to all these interventions. And what happen is this individual stay two, three puffs or one or two nebulized as short active bronchodilator several times a day. So those induce cardiac. So there is not a treatment for the disease and is significantly associated with increased, morbidity.
Amy: That's a great point. And I think we're learning more and more about the cardiovascular complications in COPD, especially that, you know, that inflammatory response you can see after an exacerbation. You'll see like shortly after that they have patients have an increased risk for cardiovascular complications.
So I guess really highlights how important Yeah.
Antonio: There are several in the last five years, prospective studies and observations [00:06:00] that highlight that when our patient has an exacerbation, the risk is not to having problems related to the lungs is the possibility to having a cardiac event. If you think about that, you know, the lung is the perfect organ for translocation.
All the blood flow goes through the lungs every three minutes. So what happened in the lung doesn't stay in the lungs. It's not like in Vegas. It stay in Vegas. It goes all over the body and you have on top of that, you have hyperinflation. You have in hypoxemia during the exacerbation, so this is a perfect storm.
You happen to have an unstead unsteady coronary plaque kind of hanging up there. This is the time the plaque is going to be loose, and this is the time the person is going to have a problem. So that's why back from the original Gold Document was propo published, sorry, in 2001 of the objectives of treatment of COPD was let's prevent exacerbations.[00:07:00]
People say, you know, these guys are crazy. So we're gonna prevent those events with bronchodilators. But what we have found in the last 20 years is that the long-acting bronchodilators, and that's the reason they're called controllers, they do prevent exacerbations and they have reduced the exacerbation rate that they used to be two, three a year to less than one a year.
Once we were able to combine those medications and start giving any single inhalers, we were able to further enhance their efficacy.
Amy: Mm-hmm. Yeah, no, I, I totally agree and I think, we're all trying to put, really highlight a lot of the recent research that describes COPD as a systemic disease, right?
Like you can affect, right, you know, the, the start with the lungs, but it can affect so many other organs and that, so why it's so important to keep the lungs under control the best that [00:08:00] we can. so that's think, I think that's a great aspect to highlight about the importance of the controller.
Medications. So, I guess do, I guess kind of going back, you mentioned that part of the reason that we have the short acting overuse is because there we kind of lack diagnosis of COPD. They haven't gotten their spirometry yet. Is, do you think there's other aspects to it? that may, maybe there's this feel like patients, maybe notice it, notice a short acting agent more, or things like that.
Antonio: What happen if you are much lower and you get something that would improve you for a uh. 10, 15% of your lung function, you will feel that. But this lower will continue to get lower and lower and lower and lower. So you going down the steps, the, the, the stairs, that's where you going. Every [00:09:00] time you go, you start from a lower point.
At the lower point it will bring you up a little bit, a lower point. what you wanna do is you wanna Hal that you want to bring him up. And keep it over there. And, and that's what patients, once they start using the long acting, they don't feel that the medication work. And if, if you combine those, they, they will feel less because the lung function is much higher.
They have this acute response. Having said that, some of the lone active, beato agonists, especially for Motorola, it has a very quick answer of action. And there are studies that have shown that even given in combination with other medications, on a steady state, the patient fill the medication and some of those are like twice a day.
So when they use the medication in the evening, they feel, oh, I'm not feeling they good this good. I'm a little sure. When they, they take the medication, it bring them back up. so they feel some, [00:10:00] efficacy. But I think the question, an important question that you asked was why is still a lot of these patients being used and especially the nebulizer, and it has to be with reimbursement and it has to be with Medicare, so Medicare.
Give these patients, this, this patient, these medications, bags of these medications that, and it's very difficult to stop it. I have patients who tell me, listen, could you send another prescription canceling this? Because I have my closet full of, of these medications and I have not needed to use it because I, I don't need it.
I'm taking my long-acting inhalers, I'm taking my controller, so I don't need this anymore. So I think it has to do with reimbursement and the other medication. The long-acting bronchodilators in some of the situations the patient will have to have for payments. And that's a very, difficult situation for some patients.
I have to look at [00:11:00] them in the eye and tell them, listen, I know you're getting these medications almost for nothing. The reason you're getting is because it doesn't work. So you, you wanna stay with that. I mean, it's fine with me, but you will be back in two years. More short of breath. You will have more exacerbations, more limited, and I may not be able to bring you back because this medications work to certain extent, will stop the progression.
Well, I dunno how much I'm gonna be able to bring you back. Another is a financial compromise at this point, but let's try to work out and find ways to help you to get the medications. So many of the companies have assistant programs, when they hit the don hole in Medica, on their Medicare part DI tell, okay, let's look at your medication.
So a cholesterol medication, you can stop it for a month. I mean, if this is gonna kill you, do you stop your cholesterol medication for a month in a cholesterol? You're not gonna shut up the roof. [00:12:00] A lot of patients stay like in Plavix after they had some intervention three years ago, I said, well probably can stop for a month this.
And if we start looking at what medication they need you, we find ways to be able to help to get the inhaler medications. Uh. I rely on samples. I run away my clinics everywhere, kind of getting samples, try to find a ways to bridge them so you know, they can, they get medications back in line with the insurance, but in some patients, it's a financial constraint that we have to work around to give them the best interventions.
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That's a great point and I think
it really highlights how important it is it is for us as clinicians to talk to patients. Kind of really tease out how often they're using like their short acting agents, and maybe the over right, trying to tease out the over users. and [00:14:00] they, but I've, I've also. there's some o there's other programs, right, that have involved, maybe not just the clinician, but maybe the, like our respiratory therapists, our pharmacists, so have, have you kind of dealt, dealt with any of those types of programs?
Antonio: So the use of SABAs are probably due for several reasons. One is for lack of diagnosis. some individuals feel short of breath. some SABAs are available at a counter, so they go and get it. They're also getting it from their provider. You, I'm a little short of breath. I smoke. Well, let's see if this will help you.
And patients receive, short acting bronchodilators and they feel when they take the medication that their symptoms gets better. unfortunately gets better for a two, four hours, but after that, they're going to be back where they were before. and this is doing nothing to stop the progression of the disease.
The other [00:15:00] overuse may have to do, especially in the Medicare patient population due to cost. this is very inexpensive medication, so patients in under Medicare, they receive these nebulized and receiving huge amounts of nebulized. So patient gets confronted with the challenge that I get this medication for free.
At the same time, if I need to get a treatment to be effective like a controller, I would have to have a financial or copayments, and I can look at the patient in the eye and tell them, you get this medication for free because it doesn't work. It doesn't do anything for you and for your disease. What we need to do is we need to stop this disease progression.
We need to improve your lung function. We need to improve your quality of life and decrease your risk of exacerbations. A lot of my patients, they understand that and, and then we try to find ways to get them to get access of the medication. So I think it's a combination. To answer your question of lack of [00:16:00] diagnosis, this patient don't have a diagnosis of CPD with, they're short of breath.
So they must have spirometry to, confirm the diagnosis. And second is for economical reasons that, and access that. This, short active bronchodilators are very inexpensive. So Medicare patients, they get it in huge amounts, but they don't work. So we need to develop ways to have access to the right medications to our patients.
Amy: Oh, that's, that's a great point. And, and I actually, we just had a really amazing article come out in the New England Journal about how we have these patients with symptoms and they, they actually had. Some kind of asthma or COPD and they weren't being diagnosed, right? They didn't have spirometry and how having that, so I think in kind of a natural environment, maybe they're just getting an inhaler and they're just getting symptomatic relief without that diagnosis.
So just, so [00:17:00] I think that's a great point. So, and highlights how important it is for us to do spirometry routinely on our patients and get a, you know, get a diagnosis.
Antonio: We need to get a diagnosis, and that's a big challenge. Let me tell you, for the last 25 years we've been looking at other ways to make a diagnosis and nothing has worked.
At the end of the day, mm-hmm. We go back to spirometry, we go back to a fixed ratio, bit less than 70%. So that's going to be the fastest and the much easier way to make a diagnosis in the future. with ai, we're going to see a lot of image. Image is going to be the next frontier for the diagnosis of COPD.
Through ai, there are algorithms being developed, have to assess the airways, have to assess the amount of emphysema, air trapping. there is a lot of new data about mucus plugs and how mucus plugs can have a. For outcome on patients and probably [00:18:00] the new interventions like biologicals, some of the efficacy may be related to the reduction of these mucus plugs.
So, and that's where the, the patients experience the improvements in lung function and feels better. So they are in the, in the clear horizon. There is opportunities through AI and, and images, but today we still rely on spirometry.
Amy: Yeah. Yeah, I totally agree about the, the ai. It's so exciting. I think also we're thinking that maybe you could diagnose some of the comorbidities of COPD with all this imaging that we have, like osteoporosis or muscle loss sarcopenia.
So, but yes, we have, we're still at this. We still have to, our patients still need to get their spirometry. That's the, that's the where we are right now.
Antonio: The goal committee, we have stated since a couple years ago that we strongly recommend that all COPD patients should get a CT chest and for [00:19:00] reasons that you mentioned, to look at other conditions like osteoporosis.
but you know, for example, it's very common to see these patient significant calcification in their coronaries.
non: And there should be some
Antonio: publication that show that 70% of the patients who had these calcifications in the coronaries, only 20% has been diagnosed or has been risk assessed. So this give us the opportunity, when we look into that, I say, good, this doesn't look good.
you know, we need to. Talk to our cardiologist. We need to do a stress test. We need to risk assess that patient. We need to look at their cholesterol, all the risk for, cardiovascular condition, but we would like to intervene before something bad happens.
Amy: Right, exactly. And it kind of goes back to how we were talking about COPD as a systemic disease.
so again, really exciting future areas, but we still need to get our [00:20:00] spirometry right now.
Antonio: Got it.
Amy: So yes ma'am. And I think there's some, there's also a lot of interesting research going on with smart inhalers. Have you kind of, encountered those where they, they kind of, give you information on how well you're doing?
Antonio: There is a delivery device that was approved several years ago. very, very interesting. the challenges have not taken off, and it is for several reasons. So basically this device connects to an application and we'll remind the patient, Hey, it's time to you to take your controller medication, to take your, your, you know, non-acting bronchodilators.
Or hey, you're taking too much of albuterol, you should not be using that much of albuterol. so the application will interact with the patient. The, this is smart delivery. devices also will give a patient immediate feedback while they [00:21:00] use the medication in their inspiratory flow was correct and the medication was able to enter the lung.
The challenge has been. All this data that is collected by the the device, how can that data be transferred to the provider? Because you as a healthcare provider, you don't wanna be, wanted to receive every five minutes from every patient. Say, Mr. Johnson used to post theia. Hey, Ms. Williams did this, did that, and once the liability was associated with that.
So the information is there and the companies are working with algorithms have to streamline. Was a couple, two weeks ago at the European Respiratory Society, meeting, there were some of those device presented. They, and they are, they presented some softwares to be able to streamline the information to the provider and develop [00:22:00] some alert systems both for the patient swell to the provider.
So, for example, to tell the patient, Hey, you have used too much abut in the last 24 hours, you probably may have an exacerbation, something wrong. You need to look for help, alert the provider. You know, your patient has been using too much rescue. they should, we instructed to look for help. So try to get it both ways.
So that has been the main challenge, but I can see the, this is only the beginning. the, with AI and all these technologies ready available, we are going to see in the near future more and more these smart devices available.
Amy: Yeah, that's a great point. Like maybe we can harness AI to maybe re reduce some of the information, right?
Like there's so much information that's coming from these inhalers. Maybe it can give us like a, a, a scorecard or something like that when we come see our patients in clinic instead of this, [00:23:00] this, all this, it's just so much information, right? That you, that these devices are giving. Yeah,
Antonio: this, for example, when you get the, the reading of the CPAP on a patient, you get every single night, every single night for the last month, right?
Get all these numbers, all this, and you are, what I do is, you know, I have to confess, I cheat because I go and look at the graph. Not the graph looks at the same level. That means that the patients did, well use it every day, but there pages and pages. So all that has to be, has to become in a manageable way, has to be accessible to the provider and more important to identify potential risk of any problem in advance.
Amy: Mm-hmm. Right. There's, you need something practical. That's a good point. Yeah. so that's, no, I think that we kind of discussed a lot of aspects of controller medications and how important they are. I, I think, do you have any other, any other thoughts on how we [00:24:00] can kind of help as clinicians to make sure our patients are on the right medications?
Kinda where, where things are going in the future.
Antonio: Okay. We need to start with the principle that what this medication did show us is that COPD is a treatable disease. What has happened in the lungs can be reverted and a lot of those can be improved. As a consequence of that, all the healthcare systems are reported significant decrease in mortality in COPD.
So matter of fact, in the US the U US used to be the third living cost of death. Now is the fifth or sixth living cost of death. It depends. You see the 24 or the 23 or 24th statistics? so we have impacted. So it is a treatable disease, but it's treatable if the patient is on the right medications. The treatment of this medi, medi, condition are the use of long-acting bronchodilators, the controller medications.
Now, the future is very excited because there is not only all these [00:25:00] medications, okay, we have the bronchodilators, we can hit the ceiling. There is no more. But now we having biologicals coming to COPD, we have two biological that had. Recently been approved by the FDA, has unfor shown that you can increase more lung function.
We thought we had reached the ceiling with inhaler. That's why you can get another 15 MLS out of that. and they are impacting the inflammation within the airway. So it is very exciting to understand that maybe other pathways, other mechanisms. We also recently have a new class of medications approved by the F-D-F-D-A, the phospho, Eter three and four, uh uh mm-hmm.
Saying, antagonist medications, and these medications is a bronchodilator and the anti-inflammatory is a very good mucolytic also. So these completely different pathways of action. So the future for our patients [00:26:00] couldn't be more exciting, but we have cures. But at the end, we need to start with prevention.
We need to emphasize smoking cessation. And the tragedy that we live in today is electronic cigarettes everywhere. All these kids using it, you know? I mean, I would tell you something really, really horrible. I was in a plane. 32,000 feet flying, from Charlotte to Phoenix. And a gentleman sitting in front of me in the seat got his electronic cigarette and he popped there in the middle of the fly on the plane.
So that addiction to nicotine that he had Yeah. Is horrible. They just can, he cannot do it. I mean, he now, you know, all this being substituted with these pot, so they put in their mouth, you see all these people putting the stuff. Nicotine. So the, the challenges for the future is still are very big. but we need to emphasize the need to prevention, the need to stop all [00:27:00] this.
But we don't wanna be confronted in 20 years with another huge epidemic of nicotine addiction with severe cardiovascular and pulmonary diseases.
Amy: Oh, exactly. I, I love these two. It kind of made these two really amazing points, which is we have all these new therapies for COPD. So oftentimes I think I'll see a patient in clinic and maybe they're like, well, you know, I don't think there's anything else.
There's anything more we can do. And you know, I, I, there's, there's nothing really that, that we can try. And I just, I've, I've never felt like, I've never had a patient where I've felt that way. I felt like we, there's usually something new and we haven't tried or we haven't changed a therapy or we have the, all these new amazing, drugs and medications coming out, particularly biologics.
and like you mentioned, the new phosphodiesterase three, four. so it's. I, I completely agree. It's a very exciting time. but you're right. We have [00:28:00] these new barriers. We have these, we, these things that, just the practical aspects like smoking cessation and e-cigarettes that we really have to work on as well.
I think that's a great, great point. Um. So I think, again, it's just, it's just wonderful to talk with you about COPD. I think we're in such an exciting age and, and again, we just love to have you on the podcast. So thank you again, Dr. Anto, for being here.
Antoniof: Thank you very much, Amy. Thank you very much for ATS for inviting me, and I'm looking forward to participating in the future.
non: Thank you for joining us today. To learn more, visit our website@thoracic.org. Find more ats, breathe Easy podcasts on transistor, YouTube, apple podcasts, and Spotify. Don't forget to like, comment, and subscribe, so you never miss a show.