Pharmacotherapy Management of COPD Exacerbation (PCE)

The percentage of persons 40 years of age and older who had a chronic obstructive pulmonary disease (COPD) exacerbation during the measurement period and were dispensed appropriate COPD medications.

Why it Matters

Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by the chronic presence of respiratory symptoms due to abnormalities and/or emphysema causing persistent and often progressive airway obstruction ^[1]. COPD is primarily caused by harmful exposure to gases, including cigarette smoke which is the most common cause of the condition globally ^[2]. COPD typically presents in smokers and individuals ages 40 years and older, and the likelihood of being diagnosed with COPD increases with age ^[2]. According to the CDC, approximately 16 million adults have been diagnosed with COPD; however, it is estimated that millions more are living with the disease without a diagnosis ^[2,3]. Annually, COPD medical costs equate to a total of approximately $24 billion for patients ages 45 years old and older, with prescription drugs making up $11.9 billion dollars and inpatient costs accounting for $6.3 billion ^[2].

Rural communities often face higher rates of COPD, hospitalizations and mortality due to common but complex influences. There are often higher levels of exposure to cigarette smoke, lung irritants from farming, mining or manufacturing occupations and fewer opportunities to access preventive or specialized care ^[4]. These exposures can further exacerbate disparities in COPD outcomes in Black and Hispanic patients ^[5]. Black and Hispanic individuals often also make up larger proportions of low wage, high risk and increased manual labor roles in the workforce, which increases exposure to risk factors that contribute to COPD development ^[6].

COPD exacerbations directly impact the long-term health and functionality of one’s lungs. Tissue damage, inflammation and oxidative stress (a process that damages DNA and cellular structures) resulting from exacerbations accelerate the decline of lung function and can lead to worsened respiratory symptoms including increased breathlessness, coughing and sputum production ^[7,8]. Frequent exacerbations can lead to more frequent hospitalizations, increased medication use and a feeling of lack of control over one’s health. Over a long period of time, COPD exacerbations are linked to an accelerated decline in lung functionality and an increased risk of mortality ^[8].

Managing COPD Exacerbations

While the underlying lung damage from COPD is irreversible, improvement to lung function is possible with appropriate treatment and lifestyle changes. Proper treatment of COPD can prevent worsening conditions which can lead to more severe conditions such as lung cancer and heart disease ^[9]. Clinical guidelines outline appropriate pharmacotherapy and non-pharmacotherapy strategies to manage COPD exacerbations and long-term maintenance care ^{[1, 10]}.

Initial pharmacologic therapy is guided by the results of the initial assessment and should account for comorbidities and patient preferences. Asthma comorbidities are particularly critical to consider, as pharmacologic therapy for combined COPD/asthma presentations should be based on clinical guidelines for asthma rather than COPD. After accounting for these comorbidities, the Global Initiative for Obstructive Lung Disease (GOLD) recommends defining COPD symptom severity and exacerbation frequency using the “ABE” framework to inform treatment.

Non-asthmatic COPD patients in Group A of the GOLD ABE tool (0-1 exacerbations per year, none leading to hospitalization) should receive a long-acting muscarinic antagonist (LAMA) or long-acting beta-agonist (LABA); however, a LAMA is preferred as monotherapy. Non-asthmatic COPD patients in Group B (0-1 exacerbations per year, none leading to hospitalization) or E (2+ exacerbations per year, none leading to hospitalization OR 1+ exacerbations per year leading to hospitalization) present more severe symptoms or exacerbation risk and should receive a combination of LABA and LAMA therapeutics. All non-asthmatic COPD patients may also receive a short-acting beta agonist for acute symptom relief ^{[5, 11]}.

Historical Results – National Averages