Chronic obstructive pulmonary disease (COPD) is a complicated health problem with multi-factorial risk factors leading to frequent and recurrent acute exacerbations. COPD includes both chronic bronchitis and emphysema and is a major cause of morbidity and mortality in the United States, particularly in the 65 years and older population. Appropriate and timely pharmacologic treatment of acute exacerbations is essential to minimize or avoid repeated hospitalizations that are costly to a burdened health care system.

COPD is a progressive disease leading to the gradual loss of lung function. It is the fourth leading cause of death in the United States.¹ The social and economic burden associated with COPD is substantial and continues to increase. In 2005, an estimated 721,000 hospital discharges were reported, and the estimated total cost of COPD in 2007 was $42.6 billion.² The World Health Organization projects COPD to be the third leading cause of death in 2020 due to an expanding epidemic of smoking, increasing pollution, and changes in the aging demographics.³

Acute exacerbations account for the largest cost (58 percent of total costs attributed to hospitalizations) for the treatment of COPD.⁴ The American Thoracic Society (ATS) and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) define exacerbation of COPD as “an acute change in a patient’s baseline dyspnea, cough, and/or sputum beyond day-to-day variability to warrant a change in therapy.”^1,4 Exacerbations typically manifest as increased sputum production, more purulent sputum and/or worsening of dyspnea.⁵ Although infectious etiologies account for 50 percent of exacerbation episodes, exposure to allergens, pollutants or inhaled irritants also play a role.^3,4,5 A patient’s symptoms and lung function may take several weeks to recover from an exacerbation episode.³ It is therefore vital that acute exacerbations are managed appropriately. The ATS has recommended strategies for the management of exacerbations (Figure 1) which include the use of pharmacological agents such as beta₂-agonists, anticholinergics, corticosteroids, methylxanthines, and antibiotics when indicated.³

Short acting inhaled beta₂-agonists (e.g. albuterol) are the preferred bronchodilators for treatment of exacerbations and should be administered as soon as possible.^3,5 When prompt response does not occur, the addition of an anti-cholinergic (e.g. ipratropium, tiotropium) is recommended. The use of methylxanthines such as aminophylline and theophylline may help to improve diaphragmatic function. These agents are considered second-line therapy due to their potential for toxicity and side effect profile and are used only when there is inadequate or insufficient response to short acting
beta₂-agonists, anticholinergics, and corticosteroids.^3,4

Investigations have shown that at least 50 percent of patients have high concentrations of bacteria in their lower airways during exacerbations.³ Studies have shown antibiotics to have a small but important effect on the clinical recovery and outcome in some patients; however, the lack of a well designed, prospective trial limits the ability to recommend that antibiotic therapy should be a part of the standard of care.⁴ On the basis of current available evidence, antibiotics should be given to the following patients:³

• Those with exacerbations with the following three cardinal symptoms of COPD: increased dyspnea, increased sputum volume, and increased sputum purulence
• Those with exacerbations with two of the above cardinal symptoms, if one of those symptoms is increased purulence of sputum
• Those with severe exacerbation requiring mechanical ventilation

Approximately one-third of patients discharged from the emergency department (ED) with acute exacerbations have recurrent symptoms within 14 days, and 17 percent relapse and require hospitalization.¹ Numerous studies suggest the use of systemic corticosteroids to be initiated at the first sign of exacerbations. Prescribing a short course of corticosteroids provides significant benefits to patients with exacerbations.⁵ This therapeutic regimen will result in physiologic improvement over the first 72 hours and increase the patient’s FEV₁. Further benefits include a decrease in both the duration of hospital stays and the odds of a treatment failure over the subsequent 30 days.⁴ In addition, by decreasing the number of exacerbations during a period of time, patients are less likely to suffer frequent exacerbations in the future and will also maintain longer disease-free intervals.⁴ No set criteria have been established to determine which patients will benefit the most from corticosteroid therapy; therefore, all patients who do not have serious contraindications should receive systemic corticosteroids.⁵

A 12-month retrospective analysis of Medi-Cal fee-for-service recipients, from October 2006 to September 2007, was conducted to determine whether members 40 years of age and older who had an acute inpatient discharge or ED encounter were dispensed appropriate medications. The analysis included specific diagnosis codes, procedural codes, and criteria from “Pharmacotherapy Management of COPD Exacerbation” by the National Committee for Quality Assurance (NCQA) for HEDIS 2008.⁶

Chart 1
Analysis Using Healthcare Effectiveness Data and Information (HEDIS) Criteria
7419	Total patients included in the analysis
6301 (85%)	Patients filled a prescription of bronchodilators within 30 days of episode date†
4737 (64%)	Patients filled a prescription for corticosteroids within 14 days of episode date†

† Episode Date: Date of discharge for acute inpatient claim/encounter or date of service for ED claim/encounter.

The result of the analysis (Chart 1) indicates that 36 percent of patients did not fill a prescription for corticosteroids. A further analysis of these patients shows that 53 percent were admitted to a hospital stay for COPD within seven days of the episode date.

In addition to appropriate pharmacologic therapy, non-pharmacologic preventative measures also need to be taken by all COPD patients. Improving exercise tolerance through regular exercise as well as adopting and maintaining a healthy lifestyle may help slow the progression of COPD. Decreasing exposure to occupational dusts and chemicals and indoor pollutants would also diminish risks attributed to COPD exacerbations. Exposure to second hand smoke may also contribute to respiratory symptoms and COPD by increasing the lungs’ total burden of inhaled particles and gases.³

First hand cigarette smoke is the most detrimental and most commonly encountered risk. Smoking is attributed to a greater annual rate of decline in FEV₁ than any other risk factor; hence, elimination of this risk factor would be an important step toward the prevention and control of COPD. The GOLD report states that just three minutes of counseling to urge a smoker to quit smoking results in a 5-10 percent smoking cessation rate.³ It is therefore recommended that this is the very least that providers should do for every COPD patient at every office visit.

Another important preventive measure is active immunizations, including influenza and pneumococcal vaccinations; both of which are covered by Medi-Cal. Influenza vaccinations will reduce serious illnesses and deaths by 50 percent in COPD patients.³ Pneumococcal vaccination, currently already recommended for patients age 65 years and older with or without COPD, can also be highly beneficial for patients younger than 65 years with a predicted FEV₁ <40 percent.³ Vaccination against pneumococcal disease reduces the risk of community-acquired pneumonia in patients with COPD and the likelihood of bacteremia in patients with pneumonia.^1,3

Frequent exacerbations are often associated with impaired quality of life and a faster decline in lung function over time.⁴ Although pharmacological therapy can help to decrease symptoms and/or complications associated with this disease, currently, there are no existing medications that can modify the long-term decline in lung function of COPD. It is vital that appropriate acute exacerbation management, chronic drug maintenance, and non-pharmacologic measures are taken to control symptoms and reduce the frequency and severity of exacerbations, sequentially preventing long-term complications.

Medi-Cal recommends following the American Thoracic Society standard guidelines for the treatment of acute exacerbation of COPD for patients:

Figure 1. COPD Treatment Algorithm

References

1. American Thoracic Society. COPD Guidelines: Standards for the Diagnosis and Management of Patients with COPD. http://www.thoracic.org/sections/copd/index.html
2. American Lung Association. Trends in COPD (Chronic Bronchitis and Emphysema): Morbidity and Mortality, December 2007: http://www.lungusa.org/atf/cf/{7a8d42c2-fcca-4604-8ade-7f5d5e762256}/COPD_DEC07.PDF
3. Rabe KF, Hurd S, Anzueto A, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Gold Executive Summary. Am J Respir Crit Care Med 2007; 176:532-555
4. Anzueto A, Sethi S, Martinez FJ. Exacerbations of Chronic Obstructive Pulmonary Disease. Proc Am Thorac Soc 2007; 4:554-564
5. Hunter MH, King DE. COPD Management of Acute Exacerbation and Chronic Stable Disease. American Family Physician 2001; 64:603-611
6. National Committee for Quality Assurance (NCQA). HEDIS 2008; 2:103-105