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


COPD Management: Clinical Insights into the Future


GOAL
The goal of this issue is to provide physicians with the most current information available for the treatment and management of chronic obstructive pulmonary disease.

PROGRAM SERIES RATIONALE
This program is designed to provide pulmonologists and primary care physicians with current and practical information regarding the diagnosis and treatment of chronic obstructive pulmonary disease (COPD). There are currently many treatments that can be effective in helping to control symptoms and improve both lung function and quality of life in patients suffering from COPD. Yet, in spite of their relative efficacy, these current treatments do not target all of the manifestations of the disease state, and some may even have serious adverse effects. It is in response to these limitations and flaws that the development and application of new drug therapies, aimed to reduce the effects of inflammatory and abnormal airway-secretory responses in patients, has become a great need and a focus of significant efforts. This program will explore the existent "space for improvement" in the current management and treatment of COPD. Implementation of proper and timely diagnostic strategies, coupled with a thorough knowledge of current treatment and upcoming treatment options, should help to reduce the burden of COPD in the lives of those suffering from the disease.

TARGET AUDIENCE
This activity is designed for pulmonologists and primary care physicians. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

  • Identify smoking cessation as a key component in COPD prevention
  • Recognize the potential role of spirometry in the early diagnosis of COPD
  • Review the current pharmacologic therapies, and identify new therapies for the management of COPD
  • Assess the need for improvement in current COPD management guidelines in relation to everyday clinical practice

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

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 1 category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

The estimated time to complete this educational activity: 1 hour.

Release date: April 15, 2003. Expiration date: April 15, 2005.

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 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 program is supported by an unrestricted educational grant from GlaxoSmithKline.

Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, an HMG Company. P.O. Box 340, Somerville, NJ 08876. (908) 253-9001. Web site: www.galenpublishing.com. Copyright ©2001 by Galen Publishing, LLC. 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. Bulk postage paid at Somerville, NJ Post Office and at additional mailing offices. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC. Printed on acid-free paper. BPA Membership applied for December 2000.

Full Disclosure Policy Affecting CME Activities:
As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant 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 Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

    Robert A. Wise, MD
    Professor
    Pulmonary and Critical Care Medicine
    Johns Hopkins University
    Baltimore, Maryland
    • Dr Wise reports receiving grant/research support from Boehringer Ingelheim and Otsuka Pharmaceuticals Co.

PARTICIPATING FACULTY

    Gary T. Ferguson, MD, FCCP
    Director
    Pulmonary Research Institute of Southwest Michigan
    Livonia, Michigan
    • Dr Ferguson reports receiving grant/research support and receiving honoraria from Boehringer Ingelheim and GlaxoSmithKline; and serving as a consultant to GlaxoSmithKline.

    Stephen Rennard, MD
    Larson Professor of Medicine
    Pulmonary and Critical Care Medicine
    University of Nebraska Medical Center
    Omaha, Nebraska
    • Dr Rennard reports receiving grant/research support from AstraZeneca Pharmaceuticals LP, Bayer, Boehringer Ingelheim, GlaxoSmithKline, Novartis Corporation, Pfizer Inc, Pharmacia and Upjohn, RJ Reynolds, and Roche Pharmaceuticals; serving as a consultant to Amersham Health, AstraZeneca Pharmaceuticals LP, Aventis Behring, Bayer, Boehringer Ingelheim, Fibrogen, GlaxoSmithKline, Mitsubishi, Novartis Corporation, RJ Reynolds, Roche Pharmaceuticals, and Sankyo Pharma Inc; and serving on the speakers bureau for AstraZeneca Pharmaceuticals LP, Boehringer Ingelheim, Fibrogen, GlaxoSmithKline, and Novartis Corporation.

Notice:
In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. 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.

COPD: Exploring Practical Management Strategies
Robert A. Wise, MD*

As outlined in the preceding issue of Advanced Studies in Medicine, which was devoted to chronic obstructive pulmonary disorder (COPD), this disabling lung disease is now the fourth leading cause of mortality in the United States.1 Among major industrialized nations, the United States now ranks among the highest in COPD mortality for both females and males.2 These updated statistics document a steadily increasing global parity between men and women in COPD deaths, a direct reflection of changing patterns of tobacco use worldwide and, to some degree, an indication of a greater female susceptibility to the effects of tobacco smoke.3

Interestingly, the country-by-country mortality and prevalence data do not always correlate with known rates of cigarette smoking. For example, COPD mortality among Japanese males is comparatively low despite the observed high rate of smoking in this group. Other factors influencing reported mortality and prevalence data might include diet, infectious diseases, diagnostic bias, shorter life spans, and alternative environmental exposures (eg, in underdeveloped countries such as China where use of biomass fuels for cooking might account for high rates of bronchitis).

Within the United States, the geographic distribution of COPD prevalence is similarly puzzling, with the highest rates of disease centered in mostly nonurban areas including the Rocky Mountain states, the Southwest, and the Southeast (Figure 1).2 Whether these "hot spots" of COPD can be attributed to increased rates of smoking or to other factors (eg, altitude, differences in diagnostic criteria) is unknown.

Even allowing for extreme variations in diagnostic definitions and reporting accuracy, these national and international COPD statistics are alarming. The coming toll in terms of disability and quality of life will be enormous. The World Health Organization has estimated that COPD was the 12th leading disease in total disease burden in 1990 and, as shown in Figure 2, that it will become the fifth leading cause of lost disability-adjusted life-years (DALYs) worldwide by the year 2020.4,5 By then, only ischemic heart disease, major depression, injuries from motor vehicle crashes, and cerebrovascular disease will rank ahead of COPD in terms of lost DALYs. As the disabilities from diarrhea and human immunodeficiency virus level off and perhaps even trend downward over the coming decades, the overall burden of tobacco-related disease—in no small measure fueled by aggressive cigarette exports to underdeveloped countries—is expected to double over the next 20 years.

A Focus on Proven Strategies for COPD Prevention and Management
Much remains unknown about the scope of the COPD disease burden worldwide, and the pathophysiology of this complex disease requires more investigation. Without a doubt, expanded research into the epidemiology and the molecular biology of this disease is warranted. The articles in this issue of Advanced Studies in Medicine will focus on 2 of the main strategies for dealing immediately and practically with the COPD problem. Both articles are based partly on presentations and roundtable discussions by COPD experts in Baltimore, Maryland, on November 15 and 16, 2002. The program objective was to explore the opportunities for improvement in the current management of COPD, with a goal of providing clear direction for the primary care clinician.

In the first article, Stephen Rennard, MD, professor of Pulmonary and Critical Care Medicine, University of Nebraska Medical Center, Omaha, provides a new perspective on the value and necessity of smoking cessation as a societal goal. In keeping with the theme of all of the articles in this special COPD series, Dr Rennard offers clinicians some very practical insights. However, instead of simply reiterating the important and widely available recommendations for helping patients to quit smoking, Dr Rennard probes into the biologic and behavioral mechanisms of smoking addiction and cessation. These insights into the fundamental roots of the COPD problem provide a unique springboard into a discussion of the future potential for more effective COPD prevention with scientifically targeted smoking cessation programs.

This is a fresh look at a critically important, and often neglected, phase of COPD management. In this era of genomics and molecular medicine, it is entirely natural for clinicians to feel attracted intellectually and professionally to the latest targeted pharmaceutical therapy for disease. (In fact, Dr Rennard will explore such in-development targeted therapies for COPD in the third and final issue of this COPD series.) In this issue, Dr Rennard shows how this same clinical inclination toward smarter rational targeted therapy can be applied to the biggest COPD mechanism of all: the smoker's behavior.

In the second article, Gary T. Ferguson, MD, FCCP director of the Pulmonary Research Institute of Southeast Michigan and adjunct associate professor of medicine at Wayne State University, spoke with a senior editor of Advanced Studies in Medicine about practical strategies for diagnosis and management of COPD. As he explains, the current COPD guidelines—as recommended by the American Thoracic Society, the British Thoracic Society, the European Respiratory Society, and the Global Initiative for Chronic Obstructive Lung Disease—are valuable resources but often are lacking when highlighting the top issues for busy clinicians. In the question-and-answer session with Dr Ferguson, key topics related to the early diagnosis of COPD are discussed, with a focus on the role of spirometry in making the diagnosis and initiating therapy. Dr Ferguson also responds to questions about COPD management tools such as rehabilitation and smoking cessation, current pharmacologic therapies such as bronchodilators and inhaled corticosteroids, and potential new therapies such as specific phosphodiesterase type 4 inhibitors. While the published guidelines will remain the cornerstone of evidence-based therapy in COPD, the perspective and voice of the single knowledgeable clinician often clarifies what works best in clinical practice. We hope this interview with Dr Ferguson provides such clear and practical insights into the critically important task of improving early diagnosis and management of COPD.

REFERENCES
1. Minino AM, Arias E, Kochanek KD, Murphy SL, Smith BL. Deaths: final data for 2000. Natl Vital Stat Rep. 2002;50(15):1-119.
2. NHLBI. Morbidity & Mortality: 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases. Available at: http://www.nhlbi.nih.gov/resources/docs/02_chtbk.pdf. Accessed February 27, 2003.
3. Xu X, Weiss ST, Rijcken B, Schouten JP. Smoking, changes in smoking habits, and rate of decline in FEV1: new insight into gender differences. Eur Respir J. 1994;7:1056-1061.
4. Murray CJ, Lopez AD. Evidence-based health policyÑlessons from the Global Burden of Disease Study. Science. 1996;274:740-743
5. Murray CJL, Lopez AD, eds. The Global Burden of Disease and Injury: A comprehensive assessment of mortality and disability from disease, injuries and risk factors in 1990 and projected to 2020. Cambridge Mass: Harvard University Press;1996.

*Professor, Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.





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.