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Breathing life into COPD research

pharmafile | March 21, 2019 | Feature | Business Services, Manufacturing and Production, Medical Communications, Research and Development, Sales and Marketing | COPD, GSK, feature

Alison Hollands, Vice President, Respiratory, UK Pharmaceuticals at GlaxoSmithKline, addresses the importance of implementing the latest approaches to treating COPD to help ensure UK patients receive the best care.

Helpless. Like drowning. Like suffocating. This is how people with chronic obstructive pulmonary disease (COPD) have described what having this disease feels like. For a person living with COPD, a sudden worsening of symptoms, also known as an exacerbation or ‘flare-up’, is a natural progression of their disease and can cause severe lung damage if left untreated. This can mean that breathing gets harder, being active becomes more difficult and, for many, their life in general gets much tougher.

But what is COPD? It is a lung disease that approximately three million people in the UK are living with, two million of which don’t know it yet. COPD generally affects people over the age of 40 and patients experience increasing levels of breathlessness, persistent coughing and production of phlegm. In many cases the disease develops because of damage to the lungs, for example from breathing in harsh chemicals or smoking, but we know that for one in 100 people with COPD the disease is caused by a genetic tendency called alpha-1-antitrypsin deficiency.

COPD is also the UK’s second biggest lung disease and the World Health Organization predicts that the condition is likely to be the third biggest killer globally by 2030. We know that once someone with COPD has had one exacerbation they are likely to have another one in the future, which can accelerate the progressive decline of their lung function. For this reason, reducing the risk of exacerbation is a core treatment goal for patients.

A new Taskforce for Lung Health, guided by the British Lung Foundation (BLF), launched the first ever five-year plan for lung health early in December 2018. Hearing from the BLF and members of the COPD community, I was struck by patients talking about shame: shame of having COPD; shame of having smoked; shame of being breathless. What struck me most is that if these patients feel shame, could they be less likely to demand the best care? Or even to start the conversation to get diagnosed?

Empowering patients to gain better control of their condition is important, but what does the treatment landscape for COPD in the UK look like when patients do seek help?

We are witnessing innovations in COPD with more treatment options than ever available to patients, including a range of medicines to treat different stages of the disease, pulmonary rehab and even surgical options. But the options offered to patients vary across the UK, an example of which can be seen in a variation in uptake of different classes of medicines, indicating that the care a patient receives in one region may be different to what is available in another.

It is not just locally that we see a variation in prescribing. Coming back to the UK after two years in Canada, I was surprised to see how much inhaled corticosteroids combined with long-acting beta-agonists (ICS/LABA) is still being used as a first-line treatment for COPD in the UK, when this is becoming much less common in Canada and other countries in Europe. This is one example of some of the stark differences in the adoption of global COPD guidelines – such as the Global Initiative for Chronic Obstructive Lung Disease (GOLD) – in different markets.

The Taskforce for Lung Health’s five-year plan says that when it comes to respiratory care, “getting the right treatment can depend on where you live and whether the people offering you advice and treatment are well informed about the best ways of treating lung disease”. GOLD and NICE reviewed the most recent innovations, data and evidence to recommend the optimal methods for treating different groups of COPD patients, but we also know that there are some regions that take a number of years to catch up to these updates.

Against this backdrop we also have an aging population and an increasing prevalence of COPD in the elderly. With people living longer, there is the potential for more people to develop co-morbidities alongside their COPD as they get older. Plus, with the average retirement age increasing at the same time and therefore more people working until they are much older, we may see COPD affecting people’s abilities to continue to earn a living before they can take retirement.

A lot of energy, research and expertise goes into updating COPD guidelines so that clinicians have the latest trusted, widely recognised and patient-focused advice to refer to when deciding how to treat the patient in front of them. So why do we see updates to global COPD guidelines being adopted at different rates in different parts of the world and in different pockets within our own country?

Firstly, in the UK we have the NHS, where decisions are made at both a national and a local level. This means that guidelines can be interpreted differently depending on the priorities, capabilities, capacity and budgets of different localities. Whilst different health economies should and do have different priorities based on the needs of the patients within their communities (which we know vary enormously across the country), unwarranted variation could mean that patients in neighbouring communities can access different treatments and care packages because of where they live.

We see new medicines reviewed and approved for formulary across each clinical commissioning group (CCG) and health board, and whilst this localised approach speaks to the differing patient needs within each CCG, it also means that in some cases we may see a ‘postcode lottery’ when it comes to patients accessing new medicines. So it makes me wonder: could some patients be missing out on a better quality of life because of their geography?

Secondly, with multiple guidelines that help clinicians keep up to date on the latest recommendations for COPD, there can be a time lag between when updates to guidelines are communicated, when they are reviewed by CCGs, and when they are implemented by clinicians.

In the UK we see a lot of clinical debate about the GOLD and NICE COPD guidelines, which creates more complexity for a primary care HCP when considering how best to treat their patients. This complexity could be why we see ICS/LABA being used in greater proportion than would be expected in relation to the proportion of GOLD A patients. This complexity could also mean that the innovation coming through from research organisations may not be reaching patients for some time after the value of the innovation is recognised.

All of these factors mean that within a broader respiratory community, we all have a duty to help ensure patients are diagnosed, treated, and their COPD is managed as simply and effectively as possible.

Yet despite this complicated landscape, we do see innovation in everyday COPD care. For example, introducing a discharge care bundle for patients admitted to hospital with an acute exacerbation of COPD to reduce re-admission rates, and establishing a respiratory action network for patients to help stem the growth of COPD-related hospital admissions. We’ve also seen much more of a focus in recent years on supporting at-risk groups like COPD patients with access to flu vaccination and smoking cessation. Learning from this best practice as well as implementing updates to treatment pathways recommended by global and local guidelines can only continue to improve COPD care in the UK.

So, what more can we do? Firstly, raising awareness amongst UK clinicians of the increasing COPD prevalence and the number of undiagnosed patients is important. If the severity of the disease and the challenges it poses to patients (and our health service) as they get older is better understood, updates to recommendations for the most effective and efficient ways to treat patients may be more positively received. The Taskforce for Lung Health’s report paints this picture with the combined voice of the broader respiratory community, helping to dial up the conversation around this topic.

Supporting and enabling continued scientific engagement and interactions between different respiratory experts is also critical. We’ve heard from primary care physicians that they value the opportunity to hear from secondary care respiratory experts about their experiences and recommendations because it helps them to make decisions about their own patients. We respect the value of these interactions and so have committed to supporting more educational meetings and forums to help these conversations to happen.

Finally, and perhaps most importantly, we need to recognise the value of hearing directly from patients about their treatment needs and preferences. The profile of patients with COPD is always changing as people from generations with higher expectations of the NHS and with more knowledge and curiosity about their own health are reaching the age when COPD symptoms may appear.

As patient demographics change, it becomes increasingly important that treatment options evolve alongside them. Treatments are evolving – we just need to be able to better harness this positive change for the benefit of patients.