Transcript

Lee Tetreault:

Welcome to frequently asked questions from the session: Case studies in pulmonary medicine for the primary care clinician. We are joined by Dr. Scialla. Before we begin, with these questions doctor, would you be able to reiterate a few key pointers from today's session to our audience?

Dr. Scialla:

I'd be happy to. I think that the key points I'd like to stress after finishing my talk was that spirometry is under-utilized in helping primary care physicians both diagnose and treat their COPD patients in that all patients who you think have COPD should undergo spirometry. I also would stress the importance of knowing the gold guidelines both for the assessment of COPD and importantly, once you know how to assess COPD, you then can understand better the therapeutic options that are available for your patients. Another important thing we talked about was that inhaler technique is often terrible for our patients and that we have to continually reinforce proper inhaler technique. And finally for all COPD patients good fundamental primary care includes smoking cessation counseling, vaccinations against influenza in pneumococcal as well as referrals to pulmonary rehab and strongly enforcing exercise and physical activity in our patients, and then lung cancer screening in the appropriate patient, as well.

Lee Tetreault:

Great, let's get into some questions. First, can people out grow their asthma?

Dr. Scialla:

So asthma is a chronic disease, it's a chronic inflammatory condition in the lungs. And to date, there are no therapies either inhalers other pills or these new biologics that modify the natural history of asthma. What does that mean, modifying the natural history? Well, in simple terms, that means that there is no cure for asthma. Now, the intrinsic intensity of someone's asthma, can change over time and people who had fairly severe symptoms, either in childhood or early adulthood, can have less severe symptoms, as they get older and mature into adulthood. But I like to think of it in those cases like a hibernating animal that can always wake up.

Lee Tetreault:

How can you tell the difference between asthma and COPD?

Dr. Scialla:

Well, Lee, that is a challenging question. And there are times where that is difficult to tease out. There is a lot of overlap between asthma and COPD. Patients don't often read the textbook and give you a clear idea that they have one or the other. My approach is to take a very careful medical history to look at pulmonary function testing, especially spirometry to try to tease out differences and then look at laboratory data and using those three different categories, I try to decipher the two conditions. But even in those cases, I'm not always successful. For COPD, it's important to remember that spirometry shows a non-reversible air flow limitation and also to diagnose COPD you have to have a history of an exposure to a risk factor known to cause the disease. Now, in this country that is namely, smoking. But not all patients with COPD have a smoking history.

When you have COPD it tends to manifest at an older age. Patients, often with COPD don't have childhood history of respiratory symptoms, which is also helpful in teasing these out. Patients with COPD on pulmonary function testing tend to have a reduced diffusion capacity while patients with asthma do not. Of interest, there are older patients who have had a history of life-long asthma. And when you do breathing test on them or pulmonary function test, it will look similar to COPD with non-reversible obstruction. So the take-home point here, is that it can be often challenging to decipher these two conditions.

Lee Tetreault:

What are the generic inhaler options for patients?

Dr. Scialla:

Well, that's a very good question. And unfortunately to date, there are not many generic inhaler options for patients. In 2008, the FDA banned the production and sale of chloral fluorocarbon based albuterol inhalers or CFC inhalers. Now, the unintended consequence of that was that all generic CFC inhalers both albuterol and the inhaled steroids at the time had to be replaced by more expensive patented hydrofluoroalkaline inhalers or HFA inhalers. Patent laws are complex and favor the drug companies when it comes to inhalers because the patent laws take into account the inhaler pump design, its delivery system and the formulation of medication, making it really challenging to come up with a generic alternative. For instance, the drug name, Advair went off patent in 2010 and it was only recently that a generic option for Advair, called the Airduo, it is a combination of fluticasone and salmeterol. That medication is now available as a generic. As far as albuterol goes there still is no generic option for albuterol inhalers.

Lee Tetreault:

How do you choose inhalers, for your patients?

Dr. Scialla:

Well, the textbook answer is that we individualize the inhaler for the patient based on what they can do and what they feel comfortable doing when it comes to the delivery of the medication. The reality is, is we typically choose the inhaler based on what medication is on the formulary for that patient. In my opinion, dry powder inhalers, tend to be the easiest to actuate and breathe in, but you really need to have a good inspiratory force in order to get that medication delivered to the proper areas of the lung. Dry powder inhalers can be irritating to people, from the throat and mouth standpoint and so some patients just don't tolerate them.

The metered dose inhalers and the soft mist inhalers are probably the better choice for patients who do not have a good or strong inspiratory force, but I've actually found it quite hard to predict which inhalers work best for which individual patients. And so I also have no problem switching to other inhalers especially if patients aren't improving on their current inhalers. Sometimes subtle particle size differences and delivery differences can have a substantial impact on a patient's response to inhalers.

Lee Tetreault:

What is the number one thing you recommend for all your pulmonary patients?

Dr. Scialla:

So I take care of a lot of patients who have chronic respiratory disease, and I tell them all that chronic pulmonary disease will only worsen in a sedentary person. So I am very bullish on encouraging all my patients to try to exercise and be as active as possible. Our mantra is, live to walk, walk to live. I refer a lot of my patients to pulmonary rehabilitation, which is a comprehensive program that not only provides an individualized exercise prescription for patients, but also gives them disease management education and inhaler medication. Patients learn breathing techniques and also stress management. Some patients because of orthopedic issues are quite limited in what they can do physically as far as walking. I still ask those patients to see physical therapy and come up with upper extremity exercises that they can use to keep their muscles tone. The bottom line is you have to keep moving.

Lee Tetreault:

This is great information Doctor. Thank you so much for your time.

Dr. Scialla:

It's been my pleasure, Lee. Thank you.




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