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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Giving New Hope to Patients with COPD: Evaluating Optimal Management Strategies


GOAL
To provide pulmonary medicine specialists and internal medicine clinicians with up-to-date information on chronic obstructive pulmonary disease management strategies.

TARGET AUDIENCE
This activity is designed for pulmonary medicine specialists and internal medicine clinicians. No prerequisites required.

LEARNING OBJECTIVES
At the conclusion of this activity, the participant should be able to:

  • Discuss the new and emerging pharmacologic treatments in the management of chronic obstructive pulmonary disease (COPD) and be prepared to adapt to the expanding armamentarium.
  • Assess the clinical management implications of recent key clinical trials in COPD.
  • List proven benefits and specify recommended elements of pulmonary rehabilitation for patients with COPD.
  • Identify and understand the medical, behavioral, and psychological challenges in treating COPD.

The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The estimated time to complete this educational activity: 2 hours. After reading this monograph, participants may receive credit by completing the CME test, evaluation, and receiving a score of 70% or higher.

Release date: December 31, 2008. Expiration date: December 31, 2010.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This activity is supported by an educational grant from AstraZeneca.

Johns Hopkins Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, d/b/a Advanced Studies in Medicine, an HMG Company, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2008 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC.

Full Disclosure Policy Affecting CE Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of The Johns Hopkins University School of Medicine to require the disclosure of the existence of any relevant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Course Director and Participating Faculty reported the following:

COURSE DIRECTOR

Robert A. Wise, MD
Professor of Medicine
Division of Pulmonary and Critical Care Medicine
The Johns Hopkins Asthma and Allergy Center
The Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Wise reports receiving grants/research support from Boehringer Ingelheim, Forest Laboratories, Inc, GlaxoSmithKline, Merck & Co, Inc, and Methapharm Inc; and serving as a consultant for AstraZeneca, Boehringer Ingelheim, Eli Lilly and Company, Emphasys Medical, Inc, Genentech, Inc, GlaxoSmithKline, InterMune, Mannkind Corporation, MedImmune, Inc, Novartis Pharmaceuticals Corporation, Pfizer Inc, Spiration, Inc, and Talecris Biotherapeutics, Inc.

PARTICIPATING FACULTY

Cynthia D. Brown, MD
Assistant Professor of Medicine
Division of Pulmonary and Critical Care Medicine
Charlottesville, Virginia
Dr Brown reports having no relevant financial or advisory relationships with corporate organizations related to this activity.

James F. Donohue, MD
Professor of Medicine
Chief of the Division of Pulmonary and Critical Care Medicine
University of North Carolina at Chapel Hill School of Medicine
Chapel Hill, North Carolina
Dr Donohue reports receiving grants/research support from Almiral, AstraZeneca, Boehringer Ingelheim, and GlaxoSmithKline; receiving honoraria from AstraZeneca, Boehringer Ingelheim, Forest Laboratories, Inc, GlaxoSmithKline, Novartis Pharmaceuticals Corporation, and Pfizer Inc; serving as a consultant for Argenta Discovery, AstraZeneca, Asubio Pharmaceuticals, Inc, Boehringer Ingelheim, Cogentus Pharmaceuticals, DEY, LP, Forest Laboratories, Inc, Novartis Pharmaceuticals Corporation, Pfizer Inc, Sepracor Inc, and Theravance, Inc; and serving on the speakers' bureau for AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Pfizer Inc.

Nancy Kline Leidy, PhD, RN
Senior Vice President, Scientific Affairs
United BioSource Corporation
Bethesda, Maryland
Dr Leidy is employed by the United BioSource Corporation, which provides consulting and other research services to pharmaceutical, device, government, and non-government organizations. In this salaried position, Dr Leidy works with a variety of companies and organizations. She receives no payment or honoraria directly from these organizations for services rendered.

Barry Make, MD, FACP, FCCP, FAACVPR
Professor of Medicine
University of Colorado
Co-Director, Chronic Obstructive Pulmonary Disease Program
Director, Pulmonary Rehabilitation and Respiratory Care
National Jewish Medical and Respiratory Center
Denver, Colorado
Dr Make reports receiving grants/research support from Boehringer Ingelheim, GlaxoSmithKline, National Heart, Lung, and Blood Institute, National Institutes of Health, Pfizer Inc, and Roche Pharmaceuticals; serving as a consultant for Spiration, Inc; serving on the speakers' bureau for Boehringer Ingelheim, GlaxoSmithKline, and Pfizer Inc; and serving on the advisory board for AstraZeneca, Boehringer Ingelheim, DEY, LP, GlaxoSmithKline, Novartis Pharmaceuticals Corporation, Pfizer Inc, Respironics, Inc, and Schering-Plough Corporation.

Cynthia S. Rand, PhD
Professor of Medicine
Johns Hopkins University
Department of Medicine, Division of Pulmonary & Critical Care Medicine
Joint Appointment, Department of Psychiatry
Baltimore, Maryland
Dr Rand reports serving as a consultant for Merck & Co, Inc, Novartis Pharmaceuticals Corporation, and Schering-Plough Corporation.

Andrew L. Ries, MD, MPH
Associate Dean for Academic Affairs
Professor of Medicine and Family and Preventive Medicine
University of California, San Diego
San Diego, California
Dr Ries reports receiving grants/research support from Boehringer Ingelheim; and serving as a consultant for Matria Healthcare, Inc.

Frank C. Sciurba, MD
Associate Professor of Medicine
Director, Emphysema Research Center
Division of Pulmonary and Critical Care Medicine
University of Pittsburgh School of Medicine
Pittsburgh, Pennsylvania
Dr Sciurba reports receiving grants/research support from AstraZeneca, Boehringer Ingelheim, Emphasys Medical, Inc, Forest Research Institute, Inc, GlaxoSmithKline, National Institutes of Health, Novartis Pharmaceuticals Corporation, Pfizer Inc, Roche Pharmaceuticals, and Sepracor Inc; and serving as a consultant for AstraZeneca, Boehringer Ingelheim, DEY, LP, GlaxoSmithKline, Novartis Pharmaceuticals Corporation, Pfizer Inc, PneumRx Inc, Respironics, Inc, Schering-Plough Corporation, and Sepracor Inc.

Notice: The audience is advised that an article in this CME activity contains reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Donohue — torch, doses of fluticasone,use of budesonide/formoterol combination in COPD.
Dr Make — effects of medications for COPD (ie, long-acting b2-adrenergic agonists, long-acting muscarinic antagonists, and inhaled corticosteroids) on other outcomes such as health-related quality of life and respiratory symptoms.
Dr Sciurba — endobronchial valves, dose of fluticasone in TORCH, use of budesonide/formoterol combination in COPD.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Giving New Hope to Patients with COPD: Evaluating Optimal Management Strategies
Robert A. Wise, MD*

Chronic obstructive pulmonary disease (COPD) has been diagnosed in 12 to 14 million people, yet remains widely misunderstood not only by the general population, but by physicians themselves.1 One of the most common misperceptions about COPD is that it is a disease of middle-aged, self-abusive men. But in fact, COPD is growing nearly 3 times faster in women than in men every year and is increasing most rapidly in the elderly population, often occurring in elderly non-smoking women.2 Another misperception is that cough and dyspnea are the only symptoms of COPD requiring treatment. COPD is a systemic disorder with comorbidities, such as muscle dysfunction, bone mineral loss, cardiac disease, cancer, and depression.

As we learn more about the pathobiology of COPD, a whole host of new therapeutic targets emerge. Besides emphysema, small airway disease is a key aspect of COPD.3 We have also achieved a growing recognition that mucus impaction in the small airways is a key part of disease pathophysiology and is associated with greater exacerbations and mortality.4 We do not know why only some smokers develop symptomatic COPD. Recent research has also begun to elucidate the subtle inter-relationships between tobacco smoke, viral infection, innate immune responses, autoimmunity, oxidative stress, and protease imbalance in causing COPD onset and progression.3,5 It seems likely that COPD is a conglomeration of many separate diseases with a common outcome of airflow limitation. This issue of Johns Hopkins Advanced Studies in Medicine, based on a roundtable meeting of internationally recognized multidisciplinary experts held in Baltimore, Maryland, on September 26, 2008, reviews the latest contributions to the medical literature in order to help physicians improve symptoms and quality of life in these patients.

The first article, based on a presentation by Frank C. Sciurba, MD, from the University of Pittsburgh and edited by me, reviews some of the mechanisms involved in COPD pathogenesis as potential treatment targets, then summarizes current and innovative therapeutic options. His presentation elucidated the self-perpetuating role of microbial colonization in COPD and its impact on peripheral and central airways. He also explored the overall goals of COPD treatment and what the medical literature tells us about the most effective treatments for achieving these goals.

Results from recent investigations suggest that physicians may need to rethink traditional therapeutic approaches. James F. Donohue, MD, from the University of North Carolina, reports on the recent controversy about the safety of anticholinergics—and the results of the pivotal UPLIFT (Understanding Potential Long-Term Impacts on Function with Tiotropium) trial. Dr Donohue also reviews the most recent findings from key clinical trials on COPD—with particular reference to the efficacy of combination therapy.

Nonpharmacologic interventions play an important role in COPD management. A very strong evidence base supports the use of pulmonary rehabilitation for patients with COPD, and it is now a recommended standard of care.6-8 In the past 10 years, nearly 1000 new articles have been added to the medical literature on the evolving role of rehabilitation in COPD management. Andrew L. Ries, MD, MPH, from the University of California, San Diego, reviews updated, evidence-based guidelines for rehabilitation programs in COPD. He comments on findings surrounding the cost-effectiveness of these programs as well as recommendations for maintenance strategies for pulmonary rehabilitation.

Caring for patients with COPD requires an understanding of how the disease affects an individual's life. Qualitative research, grounded in data, can inform clinical practice with key insights into the patient experience. Nancy Kline Leidy, PhD, RN, from United BioSource Corporation, reviews findings from qualitative research that provides a framework for evaluating functional limitations in COPD, and the psychological effects of the disease. She also discusses the implications of the patientÕs emotional status for clinical management.

In addition, because smoking cessation is critical to patient care, Cynthia S. Rand, PhD, from Johns Hopkins University, offers physicians a practical guide for conducting motivational interviews to help patients achieve cessation goals.

This monograph aims to help clinicians to efficiently acquire a more in-depth understanding of the pathogenesis of COPD, and practical approaches to assessment and treatment. Most important to us is to provide an optimistic approach to this disease with the understanding that we can do as much or more for our patients as we can in other chronic diseases. Indeed, this should give new hope to our patients living with COPD.

REFERENCES

1. Mannino DM. COPD: epidemiology, prevalence, morbidity and mortality, and disease heterogeneity. Chest. 2002;121(5 suppl):121S-126S.
2. Mannino D, Homa D, Akinbami L, et al. Chronic obstructive pulmonary disease surveillance – United States, 1971-2000. MMWR Morb Mortal Wkly Rep. 2002;51:1-16.
3. Hogg JC, Chu F, Utokaparch S, et al. The nature of small-airway obstruction in chronic obstructive pulmonary disease. N Engl J Med. 2004;350:2645-2653.
4. Hogg JC, Chu FS, Tan WC, et al. Survival after lung volume reduction in chronic obstructive pulmonary disease: insights from small airway pathology. Am J Respir Crit Care Med. 2007;176:454-459.
5. Tuder RM, Yun JH. It takes two to tango: cigarette smoke partners with viruses to promote emphysema. J Clin Invest. 2008;118:2689-2693.
6. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. American College of Chest Physicians. American Association of Cardiovascular and Pulmonary Rehabilitation. Chest. 1997;112:1363-1396.
7. Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173:1390-1413.
8. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest. 2007;131(5 suppl):4S-42S.

*Professor of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins Asthma and Allergy Center, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Address correspondence to: Robert A. Wise, MD, Professor of Medicine, Division of Pulmonary and Critical Care Medicine, The Johns Hopkins Asthma and Allergy Center, 5501 Hopkins Bayview Circle, Baltimore, MD 21224. E-mail: rwise@jhmi.edu.

The content in this monograph was developed with the assistance of a medical writer. Each author had final approval of his or her article and all its contents.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.