COPD Awareness Month: Pharmacists’ Role in Helping Patients Breathe Better

Over 16 million Americans suffer from chronic obstructive pulmonary disease (COPD) and it is the fourth leading cause of death in the United States.^1,2 Psychiatric conditions, activity limitations, and complications from infection are all significant obstacles within this patient population. Millions of emergency department visits and thousands of hospitalizations are related to COPD, which substantially increases economic burden.¹

Keys to managing COPD include smoking cessation, pharmacological therapy, preventative measures, and oxygen therapy.³. Medication adherence in patients with COPD ranges from 20% to 60% in real-world studies, and 54% of patients have poor inhaler technique.^4,5 Many factors are important when finding the right therapy for the patient: inhaler type and technique required; number of inhalations per day; and financial obtainability.^1,3 Pharmacists can contribute to improving patients’ control of COPD and minimize complications.

A timely diagnosis of COPD leads to early intervention, in which pharmacists can play an integral role.² Increase in spirometry testing leads to a more timely diagnosis giving way for early, pharmacist-made interventions and better quality of life.^2,6 A health center study found referrals for spirometry testing were significantly higher in the pharmacist intervention clinic as compared to the control clinic (47.2% vs 7.7%).⁶ Another study of physician-referred patients showed pharmacist-conducted spirometry testing improved patient convenience, led to timely diagnosis, optimized drug therapy regimens, tailored education plans, and improved long-term management.⁷ Targeting patients in community pharmacies with frequent symptoms and rescue inhaler refills can lead to increased recommendations for diagnostic tools.² A study comparing 2 community pharmacies (1 control and 1 pharmacist intervention group) showed that when pharmacists target patients with high-dose steroid and antibiotic use, treatment regimens are improved by initiating therapy and making necessary adjustments.⁸

Pharmacist counseling in multiple settings has demonstrated superior outcomes in COPD patients. Education shown to improve outcomes include disease state background, inhaler technique, medication adherence, and self-management through lifestyle changes. An outpatient study evaluating different methods of teaching inhaler technique showed that direct pharmacist instruction resulted in significantly more accurate inhaler technique compared to reading the package insert (72.2% vs. 16.7%). Additionally, direct pharmacist instructions faired between than watching videos (11.1%), or videos combined with reading the package insert (16.7%).⁹

Pharmacist involvement can also reduce the need for acute care. One study revealed that counseling by pharmacists in ambulatory care clinics, including a customized action plan directing patients to initiate certain therapy in the event of an exacerbation, decreased emergency department visits by 50% and hospitalizations by approximately 60% (p=0.02; p=0.01).¹⁰ Another study evaluating the impact of 2 counseling sessions by community pharmacists 1 month apart showed a 72% decrease in hospitalizations (p=0.003).¹¹ Of note, counseling factors consistently included a focus on medication adherence and technique, which emphasizes the importance of including these components when counseling patients with COPD. Adherence can be further supported by pharmacists suggesting combination products, generic options, and patient assistance programs, as they are the primary resource to patients when it comes to addressing affordability issues.²

Antibiotic stewardship in acute exacerbations of COPD is becoming an increasingly important responsibility for pharmacists as the rates of antibiotic resistance continue to rise.¹² Respiratory tract infections are one of the most common causes of COPD exacerbations. Clinical guidelines recommend the use of antibiotics when cardinal symptoms (increased sputum purulence, increased sputum production, dyspnea) are present; however, a review of prescribing patterns at 2 large academic centers showed a 75% rate of inappropriate antibiotic use, the most common being fluoroquinolones (58.7%).¹² Pharmacists can educate providers on proper indications for antibiotics, avoidance of unnecessary antibiotics, choosing a correct agent, and de-escalation of therapy.¹²

Facilitating and encouraging smoking cessation is another essential duty for the pharmacist. Smoking cessation is the leading modifiable risk factor for COPD and the only proven way of slowing down disease progression.^3,13 The benefits of smoking cessation on COPD progression are measurable within the first year of abstinence. After several years the rate of decline in lung function becomes similar to individuals who have never smoked, which is evidenced by a reduced risk of hospitalization and total mortality.¹³ Pharmacists can recommend individualized over-the-counter nicotine replacement therapies or pharmacologic interventions to help achieve and sustain cessation while minimizing potential untoward effects.²

Lastly, as the leading provider of immunizations, it is a pharmacist’s responsibility to ensure that patients with COPD receive their pneumococcal, COVID-19, and annual influenza vaccine because COPD patients are at high risk of complications from these infections.^3,14,15 For example, in a study of geriatric COPD patients followed over 3 influenza seasons, when both influenza and pneumococcal vaccines were given concomitantly, the reduction in hospitalizations for pneumonia (63%) and death (81%) were higher than for either single vaccine.¹⁵

The month of November is recognized for encouraging awareness of COPD. Pharmacists have the potential to make a positive impact by screening patients, providing counseling, encouraging beneficial interventions, and helping tailor patient regimens based on personalized needs. Increasing such pharmacist-made interventions could be a breakthrough in the management of COPD, which should be a major priority for our profession.

REFERENCES

1. Centers for Disease Control (CDC). Chronic Obstructive Pulmonary Disease. 2021.
2. Bluml BM. White paper on expanding the role of pharmacists in chronic obstructive pulmonary disease. J Am Pharm Assoc. 2011;51(2):203-11.
3. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of COPD Report. 2020.
4. Bengston LGS, Bancroft T, Schilling C. et al. Development and validation of a drug adherence index for COPD. J Manag Care Spec Pharm. 2021;27(2):198-209.
5. Sanaullah T, Khan S, Masoom A. et al. Inhaler use technique in chronic obstructive pulmonary disease patients: errors, practices, and barriers. Cureus. 2020 Sep;12(9).
6. Whitner JB, Mueller LA, Valentino AS. Pharmacist-Driven Spirometry Screening to Target High-Risk Patients in a Primary Care Setting. J Prim Care Community Health. 2019;10:2150132719889715.
7. Hudd TR. Emerging role of pharmacists in managing patients with chronic obstructive pulmonary disease. Am J Health Syst Pharm. 2020;77(19):1625-30.
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9. Axtell S, Haines S, Fairclough J. Effectiveness of Various Methods of Teaching Proper Inhaler Technique: The Importance of Pharmacist Counseling. J Pharm Pract. 2017;30(2):195-201.
10. Khdour MR, Kidney JC, Smyth BM, McElnay JC. Clinical pharmacy-led disease and medicine management programme for patients with COPD. Br J Clin Pharmacol. 2009;68(4):588-98.
11. Tommelein E, Mehuys E, Van Hees T, et al. Effectiveness of pharmaceutical care for patients with chronic obstructive pulmonary disease (PHARMACOP): a randomized controlled trial. Br J Clin Pharmacol. 2014;77(5):756-66.
12. Dietrich E, Klinker KP, Li J, et al. Antibiotic Stewardship for Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Am J Ther. 2019;26(4):499-501.
13. Wu J, Sin DD. Improved patient outcome with smoking cessation: when is it too late?. Int J Chron Obstruct Pulmon Dis. 2011;6:259-67.
14. Arabyat RM, Raisch DW, Bakhireva L. Influenza vaccination for patients with chronic obstructive pulmonary disease: Implications for pharmacists. Res Social Adm Pharm. 2018;14(2):162-69.
15. Nichol KL. The additive benefits of influenza and pneumococcal vaccinations during influenza seasons among elderly persons with chronic lung disease. Vaccine. 1999;17 Suppl 1:S91-S93.