Breathless w/ COPD

New LABA/LAMA combination, given o.d. improves symptoms and health-related quality of life

DR. NAPOLEON APOLINARIO started smoking at the age of 18. He says he belongs to a “macho” generation where smoking is considered a thing for macho guys.

“If you’re not smoking, you are not macho. Practically all movies that you see years back showed famous actors and actresses smoking. All magazines and newspapers have big advertisements of cowboys smoking in the Marlboro country,” said the former director of the University of the Philippines-Philippine General Hospital.

Dr. Apolinario admitted that when he started smoking, the sticks became packs during his long days and nights in the medical school and during his residency training. By the time he was a practicing orthopedic surgeon, he became a one-pack-a-day smoker.

When he started having smokers’ cough, his family urged him to quit, but their pleas fell on deaf ears. “Ako ay nagbibingi-bingihan. (I pretended not to hear them) Why would I stop? I was as healthy as a bull, and a muscular macho man who felt invincible like Superman. I could even dance the night away just like John Travolta. I imagined myself as a hotshot surgeon who was entitled to living in a fast lane and nobody, nobody was going to tell me what to do to live my life,” he said.

But after 34 years of smoking, Dr. Apolinario started wheezing. Initially, he did self medication but eventually he consulted a pulmonologist when his breathing became labored.

“I was warned that I have the beginning of COPD (chronic obstructive pulmonary disease). But I was in denial and kept telling my family that it was just a little asthma,” said Dr. Apolinario.

6th leading cause of death

COPD is a major health issue worldwide. The disease is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced, chronic inflammatory response in the airways or lung to noxious particles or gasses.

In the Philippines, COPD is the sixth leading cause of death. The Burden of Constructive Lung Disease (BOLD) study found that COPD prevalence in Manila was 14 percent while two towns in Nueva Ecija had a prevalence rate of 21 percent. Aside from the high prevalence rates, only 2 percent of these cases were diagnosed by doctors.

Overall, 28.3 percent (17.3 million) of the Philippine population aged 15 years old and over currently smoke tobacco; 47.7 percent (14.6 million) are men, and 9 percent (2.8 million) are women. The majority of deaths attributable to smoking are caused by COPD and cerebrovascular diseases.

According to Dr. Teresita De Guia, national leader of the Global Initiative for Obstructive Lung Disease (GOLD), most people with COPD are smokers or were smokers in the past. Any form of smoking can cause COPD. It can also be caused by environmental exposure (e.g. biomass fuel) and genetic factor due to alpha-1 antitrypsin (AAT) deficiency.

Although Dr. De Guia said that we can still do something about COPD, the problem is there’s lack of public awareness and lot of misconceptions about it.

Dr. Tim Trinidad, chair, Council of COPD and Pulmonary Rehabilitation of the Philippine College of Physicians revealed that people often equate shortness of breath to old age; if someone’s not feeling well, he’ll take a rest and he’ll get better; or that COPD is not treatable.

“COPD attacks the lungs gradually. It’s a progressive and silent disease,” said Dr. Trinidad.

Symptoms include shortness of breath, coughing, wheezing, chest tightness, and others. Many patients with COPD experience exacerbations, a sudden worsening of symptoms most commonly caused by infections of the upper respiratory tract or tracheobronchial tree.

Turning point

It’s been 24 years since Dr. Apolinario quit smoking, but unfortunately, his condition gradually became a full blown COPD just when he was riding the crest of his career.

“It was ironic that here I was feeling on top of the world, not just as a surgeon but also as a hospital administrator and very active in the academe as professor in the orthopedics but I was already feeling I could drop dead anytime,” said Dr. Apolinario. He couldn’t finish a sentence without coughing; couldn’t climb the stairs without gasping for breath; and couldn’t dance anymore without fear of collapsing.

Just in time he retired from all his administrative and teaching jobs, he still went on to his medical practice, but he had to shorten his clinic days and hours. Occasionally during bouts of respiratory distress, he would ask pulmonologist friends for advice whenever he sees them in the elevators or corridors.

“Doctors are not the best patients. In fact, I think they’re the worst patients. We tend to self-diagnose, self-medicate, that is why our illnesses are sometimes not treated promptly and appropriately. By the time we formally consult especially for our particular illness, there is already many ‘if onlys’. If only I have done this, if only I’m treated,” said Dr. Apolinario.

Last September 2014, Dr. Apolinario had his worst episode of incessant coughing, difficult breathing, and easy fatigability. What was alarming then that time was he kept on choking while eating.

“Parang nalalagot ang aking hininga. Pakiramdam ko ay isang bulate na lang ang ‘di nakakapirma sa aking death certificate,” (I was really short of breath, and felt close to death) he said jokingly.

A month after, he read about a breakthrough medicine, which became his life’s turning point. It made him realize the important roles of the following: 1) media in disseminating information on new life medicine and treatments to the general public; 2) proper consultation to have the right diagnosis and treatment; and, 3) the availability and steady supply of a very rare drug, especially those that can mean life and death.

“Having a COPD is a lifelong challenge. But it need not be, if we have the right doctor, right medicine, right information, and the assurance of a ready and steady supply, COPD patients can add more years to our life and add more life to our years.”

Treatment strategy for COPD

In 2013, the GOLD updated their Strategy for the Diagnosis, Management, and Prevention of COPD with the latest evidence for best practice.

It recommended pharmacological therapy to reduce COPD symptoms and exacerbations, and improve health status, and exercise tolerance. The choice of treatment is dependent on the individual patient’s level of symptoms, lung function, and risk of exacerbations; however, bronchodilator medications are central to the management of COPD for all.

Bronchodilators may be used as needed or on a regular basis as maintenance treatment to prevent or reduce COPD symptoms. It can be inhaled short-acting or inhaled long-acting bronchodilators.

Inhaled long-acting bronchodilators are used regularly to open the airways and keep them open for 12 hours with twice-daily dosing, and in some cases up to 24 hours (once-daily dosing; while inhaled short-acting bronchodilators are used as rescue medication and work quickly and last from four to six hours.

There are two main types of inhaled long-acting bronchodilators: long-acting beta2-agonists (LABAs) and long acting muscarinic antagonists (LAMAs).

LABAs stimulate beta2-adrenergic receptors producing cyclic AMP which promotes muscle relaxation and therefore reduces bronchoconstriction; while LAMAs block the bronchoconstrictor action of acetylcholine on airway smooth muscle cells and therefore prevent muscle constriction.

According to Professor Mario Cassola, MD, director, division of Respiratory Medicine, University Hospital Tor Vergata, Italy, combining bronchodilators with different mechanism of action may increase the degree of bronchodilation for equivalent or lesser side effects.

Combined LABA/LAMA

The GOLD strategy recommends, as an alternative choice, combined use of a LABA plus LAMA in all patients with moderate to very severe COPD (GOLD groups B-D). Administration of LABA plus LAMA as a once-daily dual bronchodilator simplifies treatment administration and may help improve compliance. The COPD Council adopted the GOLD 2014 Guideline Update recommendations and has inserted local epidemiological data to bring in local perspective of COPD.

This first once-daily dual bronchodilator combining a LABA and a LAMA is called indacaterol/glycopyrronium, which represents a new option for the treatment of COPD. It has been and is still being investigated in the PHASE III Ignite clinical trial program, one of the largest clinical trial programs in COPD involving more than 10,000 patients across 52 countries including the Philippines.

In the clinical studies, indacaterol glycopyrronium demonstrated an acceptable safety profile with no significant difference between the treatment groups (placebo, indacaterol 10 mcg, glycopyrronium 50 mcg, OL tiotropium 18 mcg, SFC 50 mcg/500 mcg in the incidence of adverse and serious adverse events.

It offers the potential to improve symptoms and health-related quality of life of COPD by improving lung function compared to current most commonly used standards of care.

“COPD is a worldwide problem. Though not curable, COPD is treatable and treatment options like LAMA and LABA can help address symptoms,” he said, adding that lifestyle change, pulmonary rehabilitation, exercising, oxygen treatment, or surgery can also be considered as treatment.

“It all begins with you. Start today. Be your own advocate. Ask questions and seek information,” he concluded.

Vital Signs Issue 77 Vol. 4, July 1-31 2015