A perspective for chronic obstructive pulmonary disease (COPD) management: six key clinical questions to improve disease treatment

ABSTRACT

Introduction

In 2011, the GOLD recommendations for the treatment of Chronic Obstructive Pulmonary Disease (COPD) introduced new clinical elements to classify the severity of the disease and to guide pharmacological choice. For the first time in the GOLD documents, treatment decision was no longer guided only by pulmonary function, but by a more complex combination of pulmonary function and clinical aspects. The recent versions of the GOLD recommendations introduce new aspects for the clinicians and pose new question for the management of the disease. In addition, inflammatory biomarkers and blood eosinophil levels, have been considered to guide treatment selection.

Area covered

The evolution of disease management proposed by the GOLD document opens several areas of debate. A series of roundtable discussions among respiratory physicians took place in Italy to address key clinical questions. Particularly, the role of lung function and the use of biomarkers, the adherence to international guidelines and the possibility to personalize the pharmacological approach in COPD patients have been discussed, summarized and analyzed.

Expert opinion

The authors believe that the development of a precision medicine approach tailoring the specific treatment for each patient is the goal of COPD management and may be achieved by considering the phenotypic classification of COPD patients.

KEYWORDS:

• COPD
• pulmunary function
• biomarker
• eosinophil count
• exacerbations
• ics
• de-escalation

Acknowledgments

This manuscript was agreed to be published by all of the participating pneumologists and the authors thank all of them for participating in the round table discussions. These round tables were supported by Boehringer Ingelheim Italy, who organized and funded them. The authors received no compensation for the preparation of the manuscript.

Article highlights

• The classification of COPD patients on the basis of the severity of the disease and on the best pharmacological treatment has been debated in Italy, following the modifications proposed by the GOLD document, to identify the clinical management and the possibility to personalize the pharmacological approach in specific groups of COPD patients.

• Lung function parameters, such as FEV1, although central in the diagnosis of COPD, may be inaccurate to predict the prognosis and to define the best treatment for COPD. The evaluation of other indices resulting from a multidisciplinary approach must be considered to address the clinical complexity of a COPD patient.

• There is the need in the daily clinical practice for the identification of easily detectable biomarkers for the assessment of COPD severity, progression and prognosis.

• There is a consistent “gap” between real-life pharmacological treatments, escalation and de-escalation treatment and GOLD recommendations.

• The development of a precision medicine approach tailoring the specific treatment for each patient is the goal of COPD management and may be achieved considering the phenotypic classification of COPD patients.

Declaration of interest

M Contoli reports personal fees from Boehringer Ingelheim, during the conduct of the study. He also reports grants and personal fees from Chiesi Farmaceutici as well as personal fees from AstraZeneca, Boehringer Ingelheim, Novartis, Menarini, Mundipharma, Almirall, Zambon and ALK Abello as well grants from the University of Ferrara, Italy. L Morandi reports personal fees from Boehringer Ingelheim, during the conduct of the study. M Carone reports personal fees from Boehringer Ingelheim, during the conduct of the study. Finally, F Di Marco reports grants and personal fees from Boehringer Ingelheim, GlaxoSmithKline, Novartis and AstraZeneca as well personal fees from Chiesi amd Zambon, Guidotti/Malesci, Menarini, Mundipharma, TEVA Pharmaceuticals and Almirall. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

One referee declares employement with GlaxoSmithKline while another declares that they have received speaker fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, Menarini, Rovi, Bial, Sandoz, Zambon, CSL Behring, Grifols and Novartis, consulting fees from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Bial, Gebro Pharma, Kamada, CSL Behring, Laboratorios Esteve, Ferrer, Mereo Biopharma, Verona Pharma, TEVA Pharmaceuticals, Spin Therapeutics, pH Pharma, Novartis, Sanofi and Grifols and research grants from GlaxoSmithKline and Grifols. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

Preparation of this paper was supported by an unrestricted grant from Boehringer Ingelheim Italy. Editorial assistance was provided by Aashni Shah and Barbara Bartolini, PhD (Polistudium SRL, Milan, Italy) and was supported by Boehringer Ingelheim Italy.