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#7 COPD Guidelines Update - Saving Lives One Eosinophil at a Time
77 Plays1 year ago
Are you checking eosinophil counts on your COPD patients? If not, it's time to start! Do you know which class of COPD medications have demonstrated a mortality benefit in RCTs? If not, you don't want to miss this one!
In the premiere episode of Season Two, Bobby and Sandy review updates from the 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. We'll talk about some of the major changes, including the new and improved initial therapy diagram. We delve into key learnings from the IMPACT and ETHOS trials, and discuss why the LABA+ICS regimens recommended in previous guidelines are now discouraged.
Episode Outline:
- Introduction - 01:35
- The new and improved 2x2 therapy initiation table - 03:40
- Recommended initial treatment - 05:58
- Use of eosinophils to guide therapy - 09:12
- Factors to consider when adding ICS - 16:33
- Adjusting therapy in follow up - 18:20
- Studies showing mortality benefit with triple therapy - 22:05
- Potential downsides of triple therapy - 25:56
- Wrap up/key takeaways - 28:23
Key Takeaways:
- LABA+ICS is out, triple therapy is in! In patients with frequent COPD exacerbations, consider triple therapy (especially if they have eosinophils>300) but beware if history of repeated pneumonia, history of mycobacterial infection, or eos <100.
- Triple therapy is the only pharmacological intervention for COPD with an associated mortality benefit
- ABCD is gone, it’s now ABE. Be sure that you are doing a formal symptom assessment like the mMRC or CAT!
- More patients are getting LAMA/LABA combination at start than previous guidelines. Now for all group B and E patients
Episode Links:
- 2023 GOLD Pocket Guide https://goldcopd.org/wp-content/uploads/2023/03/POCKET-GUIDE-GOLD-2023-ver-1.2-17Feb2023_WMV.pdf
- IMPACT Trial (2018) https://pubmed.ncbi.nlm.nih.gov/29668352/
- ETHOS Trial (2020) https://pubmed.ncbi.nlm.nih.gov/32579807/
If you liked the episode, please leave a positive review and subscribe! Tell your colleagues and friends!
Comments/Questions/Suggestions? Email us at whatstheproofpodcast@gmail.com or find us on Twitter @theproofpodcast!
Credits:
- Hosts: Bobby Scott, MD, FAAFP; Sandy Robertson, PharmD; Dawn Caviness, MD, BSN
- Production & Cover Art: Bobby Scott, MD, FAAFP
- Music: Twisterium, MondayHopes, Muzaproduction, and SergeQuadrado from Pixabay
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Transcript
Introduction to Evidence-Based Clinical Decision Making
00:00:00
Speaker
You are listening to the What's the Proof podcast, where we seek to help doctors and other clinicians incorporate the best available evidence into their everyday clinical decision making. The content of this podcast is meant for educational purposes only and should not be construed as personalized medical advice. The views and opinions expressed are those of the host and guest, and no content on this podcast has been approved or sanctioned by Atrium Health.
Key Updates in COPD Treatment Guidelines
00:00:36
Speaker
Welcome to Episode 7 of What's The Proof, a family medicine podcast that seeks to help family physicians and other clinicians incorporate the best available evidence into their everyday clinical decision making. Today, we are discussing the 2023 Gold COPD Guidelines, and while we don't have enough time to discuss everything in them,
00:00:55
Speaker
We will be highlighting a few noteworthy items. I'm Bobby Scott, practicing family physician and faculty member at Cabarrus Family Medicine Residency Program. And with me today, as usual, is my residency faculty colleague, Dr. Sandy Robertson, who's a clinical pharm D. Sandy, how are you doing today?
00:01:12
Speaker
I'm doing very well. How about yourself? I'm doing great. It's so good to be finally recording this next episode. It has been a while. I know. I'm a little ashamed, but we're going to try to make this one a good one. Yeah. Yeah. Don't forgive us. Yeah. I was thinking maybe we can call this season two of what's the proof. And this is just the episode one. So whichever sounds better, either this is episode seven or episode one of season two, we'll go with that. Um,
00:01:40
Speaker
But I'm excited about today's episode. Would you share with the audience why we decided to discuss the gold guidelines today?
Hosts Introduction
00:01:48
Speaker
I will be happy to. So 2023 rolls around and we're feeling good. And all of a sudden the gold guidelines come out. And this was a pretty quick update from the previous ones. And when I started reading it, I realized that, hey,
00:02:07
Speaker
there are some significant changes. And anytime I need to teach my residents and the faculty and everyone, that means that I have to really go in and be honest with myself about the stuff that I'm really comfortable with and then the new data. So specifically, there were four things that I felt were pretty significant about these guidelines, the 2023. So I'm going to just summarize what we're going to talk about. And then we can kind of break that down. Is that all right?
00:02:34
Speaker
Sounds great. So number one, and this was a really big one is mortality benefit with triple therapy. So we know that this is brand new. This is the first pharmacotherapy that's ever been shown to reduce mortality in COPD patients.
00:02:50
Speaker
and we will talk about that later. So that's a really big deal. Number two, confirmation. So we've already known this, but additional studies and confirmation that ESNFL counts need to be at least considered when you are choosing options to treat COPD. Number three, confirmation that bronchodilation is in fact first line therapy, first line strategies, all bronchodilation. And last but not least, the table that we all kind of know and love, the ABCD table for
00:03:19
Speaker
initiating therapy with COPD patients has now been changed to A, B, E. So CD has been replaced with E, which is meant to stand for exacerbations. So it's really not that different. It simplifies things actually, but it looks different. So I definitely needed to kind of update myself on all of these changes.
00:03:40
Speaker
Yeah, big changes. Why don't we just start within with the table that you just mentioned?
New COPD Treatment Strategies
00:03:44
Speaker
I'm sure many of our listeners are familiar with the old ABCD table that the guidelines had in previous years, but can you walk them through the new and improved version?
00:03:54
Speaker
Sure, I'll be happy to do it just very briefly. So once you make the diagnosis of COPD based on your history and physical, your PFTs, those findings, you have the patient back to discuss initial treatment. Well, you know, which way do you go? So there's some important pieces of information that you need to have. First, you need to explore their exacerbation history. And the definition of that in the table is within the previous year.
00:04:18
Speaker
So increased dyspnea, sputum production changes, along with the severity of those episodes. So even though the patient has just been diagnosed with COPD, oftentimes you can ask them questions and you can discern if in the previous year they did have an exacerbation.
00:04:32
Speaker
It just wasn't diagnosed yet. So that's the first thing you're really going to try to investigate. And then secondly, you need an objective measure of what their symptoms are. You can achieve that with either the MMRC or the COPD assessment test. These are both objective, validated tools to help you decide what the weekly symptomatology is for a particular COPD patient.
00:04:59
Speaker
Based on these two sets of information, you can now categorize patients into either A, B, or E. So if within a year they've had at least two moderate episodes, or two moderate exacerbations, excuse me, or at least one of those have led to a hospitalization, they are now automatically in group E, meaning the exacerbation group.
00:05:21
Speaker
There are no longer groups C or D. Now, if they don't meet that exacerbation criteria, then you categorize them as A or B, depending on their symptom assessment. Group A is the less symptomatic group with either an MMRC of one or less or a CAT score of 10 or less than 10. And group B has more symptoms at baseline with either an MMRC of two or a CAT score of at least 10.
00:05:48
Speaker
Yeah, these are pretty significant changes compared to 2022. Like you mentioned earlier, it simplifies the treatment. Group A is still basically the same, recommending a bronchodilator, either short acting or long acting. For group B, instead of a single-agent llama or lava,
00:06:07
Speaker
They now recommend a combination of a long-acting beta agonist, the LAMA, or the long-acting muscarinic agent, the LAMA. As you mentioned, group C and D, they're gone and replaced with group E. The authors explained that this change was meant to, quote, highlight the clinical relevance of exacerbations, end quote.
00:06:26
Speaker
But they acknowledge, though, that this still needs to be validated by future research. And for group E, they recommend also a combination of lava and llama, but with a note to consider adding an inhaled corticosteroid as well, aka triple therapy, in patients with an eosinophil count greater than or equal to 300.
00:06:48
Speaker
Correct. And conspicuously missing here is the option for the LABBA inhaled corticosteroid combination, which was an option in previous guidelines. The gold authors now discourage the use of LABBA ICS regimens in COPD. And the reason for that is that we now have ample evidence that triple therapy is superior to LABBA ICS. And so therefore, if an inhaled corticosteroid is indicated, triple therapy is going to be preferred.
00:07:16
Speaker
over that regimen. So if you have patients currently that are on the LABBA ICS regimen, the new gold guidelines would recommend you change those patients to triple therapy, meaning a LABBA, LABBA and ICS, which is superior.
00:07:32
Speaker
that that is correct. And, you know, when I'm teaching this with residents, even before the 2023 guidelines came out, they always ask about group A and how it's so, you know, a bronchodilator. And quite honestly, these are, these are evidence based guidelines, we really try to follow the literature. And quite honestly, we don't find group A, we can't study them. You see, these are people that don't have exacerbations.
00:07:55
Speaker
and they don't have a lot of symptoms. They have a diagnosis, but at that point, we really just don't know what to treat them with the best. Right, yep. And you might say that these are considerably more aggressive in using combination therapy than in previous years.
Symptomatic Treatment Recommendations
00:08:11
Speaker
For example, Group B, you're more symptomatic patients with just a few exacerbations now get that combo lama-laba instead of monotherapy. So why did they make that change, Sandy?
00:08:22
Speaker
Right, right. So again, based on the studies, so we now have multiple studies that compare a LABBA and or a LAMA alone with combination. So the LABBA-LAMA combination as the first line therapy for COPD. And either if you have moderate dyspnea or an exacerbation in the past year and the combination showed
00:08:42
Speaker
reduced symptoms, which is now considered a grade A evidence, and exacerbations, which they categorize as a grade B evidence, so both fairly strong compared to monotherapy with either class. Now, there was not an effect on mortality, but I think reduced symptoms and reduced exacerbations
00:09:00
Speaker
makes it significant that you're gonna do the combination rather than monotherapy. So for your more symptomatic COPD patient, we can now confidently state that two bronchodilators are better than one.
Corticosteroids Response and Benefits
00:09:12
Speaker
So what stands out to me is this recommendation to consider triple therapy in patients with an eosinophil count greater than 300. So Bobby, do you currently look at the eosinophil result in your differential of your CBC for a COPD patient?
00:09:30
Speaker
Well, I do that a lot more now after learning all this. I always would look at everything, but I may not pay attention necessarily to those minor details that I otherwise wouldn't have considered in just checking my usual CBC. But now it's something I really need to pay attention to and think about.
00:09:51
Speaker
Right. I think so. And I think that we've had a little bit of time to really consider this. I remember this first reading about ESNIFILs in 2019 and trying to talk to the residents about it and then other things happened in the world. And I just decided this is not something I'm going to teach.
00:10:12
Speaker
Now, I've had to come back to that. A lot of things did happen in the world around then. It did, and they were very significant events, and I just chose to leave out the, well, what was the ESNFL count? But now, I feel a little bit more confident that it's time to talk about it. Yes, and so do the people, the gold authors, so why are they emphasizing now the ESNFL counts?
00:10:33
Speaker
Right. Okay. So I'll try to explain this from a non-expert standpoint. Okay. So blood eosinophils are proposed to be an accurate surrogate marker of airway eosinophilia that can be used for the treatment decisions in patients with COPD, mainly for the identification
00:10:50
Speaker
for candidates for both initiation or withdrawal of therapy with inhaled corticosteroids, as well as the identification of patients at future risk of exacerbations. So notably, patients with low levels of blood and sputum eosinophils have a greater presence of proteobacteria, especially haemophilus. Now, in general, we know that COPD patients have been found to have higher than normal counts.
00:11:15
Speaker
And eosinophils greater than 300 identifies those at increased lung eosinophil numbers and increased inflammation that comes with it. So the current recommendation is to assess eosinophil count. Many labs report this as an absolute count, but if not, you can simply calculate that by multiplying your white blood cell count.
00:11:35
Speaker
by the percentage of the ESNFLs. So a white count of 12,000, your ESNFLs are 2%, therefore your blood ESNFL count is 240, right? So if it's less than 100, you consider no steroids, or if it's considered safe to possibly stop the steroids, if that's possible, it's at least a shared decision making.
00:12:00
Speaker
And if it's greater than 300, i.e. a lot of inflammation, you really need to consider starting the steroids. So it's just a surrogate marker that kind of gives us this threshold and another piece of information. So I find this to be of benefit. I mean, the numbers are there anyway, so why don't we pay attention to some of these markers, right?
00:12:19
Speaker
So then you've got the threshold of less than 100 and greater than 300 and I just want to make sure that we understand that these are only estimates and they should be used as just one piece of the information to determine if inhaled steroids should be prescribed. So this is not something that you die on your sword. I don't want you to see these numbers and it's absolute and we in medicine do tend to
00:12:41
Speaker
go that way if I may? Is that too? A little bit picky in particular, aren't we? We are, we are. So, but it's just a piece of the puzzle when you're trying to discern what is going to be the best therapy for your patient. So, I want to just put this in perspective. We'll talk about these trials a little bit later, but in the triple therapy trials that did show mortality benefits, so everybody's really paying attention to them,
00:13:05
Speaker
Only 15% of those patients had ESNIFILs greater than 300 and this was not a marker that was used to determine which study medication they received. So it was placebo controlled, it was ICS, Lava, etc. versus triple therapy. They recorded the ESNIFIL count but they didn't use that as a stratifying mechanism as to which therapy you were going to get.
00:13:27
Speaker
Yeah, I find the essential thing really interesting. When we were preparing for this episode, I really went down the rabbit hole on these things. So I just want to point out a couple of additional points about them. So there are now multiple randomized controlled trials, including post hoc analysis of the impact trial that we're going to talk a little bit more about here in a little bit.
00:13:47
Speaker
But again, multiple RCTs showing that elevated baseline eosinophil counts are predictive of a beneficial response to the addition of ICS. And main benefit being reduced incidence of exacerbations. But interestingly though, despite it being predictive of response to inhaled corticosteroids, the data on its use as a biomarker to predict future exacerbation risks is conflicting. You would think that, you know, if it
00:14:16
Speaker
measures the response to the steroids, then maybe you can say, oh, these people, they have high eosinophil counts, they're likely to be at high risk for exacerbations, but it's just not very clear on the data right now. No, it's not. And I think that's really important to point out because we need more data to really confirm that.
00:14:33
Speaker
Yeah. And so the gold authors recommend considering initiating triple therapy in the group E, which is the group of patients with frequent exacerbations if they have eosinophils greater than 300 with the goal of hopefully reducing those exacerbations going forward. And you may wonder, well, why not just do that for all group E patients? And the reason for that is that there's no direct evidence regarding starting triple therapy in newly diagnosed patients.
00:15:01
Speaker
So just out of caution, they recommend reserving that for now just for the patients with ESN. It feels greater than 300.
00:15:09
Speaker
And as you said, that 300 number is not a hard and fast cutoff, but actually you can consider starting triple therapy at lower levels of eosinophilia as well as some of the RCTs on those found benefits for patients that were in that range between 100 and 300. So that's a good place that you can consider having shared decision making conversations with your patients.
00:15:32
Speaker
Yes, I would agree. And secondly, as you mentioned, patients with eosinophils less than 100 at baseline are less likely to benefit from the addition of the inhaled corticosteroids. And in fact, low baseline eosinophil levels appear to be associated with an increased baseline risk of pneumonia as well. And as we'll discuss later, adding that ICS comes with its own risk of pneumonia. So you may be potentially furthering the risk of pneumonia in a group
00:16:00
Speaker
that is already at elevated baseline risk if you start them on a steroid. And then thirdly, the eosinophil levels do fluctuate some over time. So that's another reason why they aren't really a firm cutoff. But it is important to note that they don't seem to be affected by being on inhaled corticosteroids.
00:16:20
Speaker
Correct. That is correct. So very good job. And I'm so glad you went down the rabbit hole and I'm so glad you came out feeling, feeling a little bit better about it. I love this and it feels now. I spent a little bit of time there myself.
00:16:33
Speaker
So the goal guidelines, I will encourage the listeners to download the Pocket Guide. They have excellent tables. And this is certainly not anything that we have created, but they have a really good green, yellow, red table of factors to consider when initiating inhaled steroids. And so I think the wording is correct and they're not trying to boss you around and tell you what to do.
00:16:58
Speaker
You know, the green light is meaning the gold strongly favors the use of inhaled steroids in the following. Number one, history of hospitalizations for exacerbations of COPD. We know that inhaled steroids do reduce the number of repeated hospitalizations. Number two, if they've had two or more moderate exacerbations, so they've at least needed their prednisone course and their antibiotics.
00:17:22
Speaker
Number three, blood is and it feels greater than 300. Or number four, obviously, concomitant asthma. Those are going to be in the green, strongly favored. Against you, so in the red, are going to be the following. So repeated pneumonia events. And I will tell you that we don't know what that magic number is. When I'm talking to the residents, I say repeated to me means at least two.
00:17:45
Speaker
If the last one was 20 years ago, I don't know that I would count that, and it's a little bit more subjective. But repeated pneumonia events, and we'll talk about the risk with steroids. Number two, blood eosinophils, less than 100. And number three, a history of mycobacterial infection, because that in and of itself increases your risk of having pneumonia. And then in the yellow zone is just like you said, the blood eosinophil count in between 100 and 300. And then just one moderate exacerbation in the last year. So that's going to be, again, in your shared decision making.
00:18:16
Speaker
Yeah, awesome. And so let's just shift gears a little bit now and talk about, so you've started your initial treatment, you've put them on the, you know, llama, lava, or just the, or the monotherapy, depending on their, or their group.
Adjusting Therapy Based on Outcomes
00:18:29
Speaker
So you have them come back and you ask them how they're doing. And if the response to that initial treatment is appropriate, they say, wow, doctor, I love this medicine. You're doing great. We're just going to stay the course. That's what we're going to keep doing.
00:18:41
Speaker
But if not, then you need to consider a few different things. The first thing you definitely want to check is, are they adhering to the medication? Particularly, there's all sorts of inhalers. They all work a little bit differently, but most of them are fairly similar. But sometimes patients get confused on how to use them. So you just want to make sure that they're using them properly. Correct. And before you judge that, I would like to ask the listeners, how many of you have tried to
00:19:10
Speaker
appropriately use an inhaler they're harder they're harder than you think they're not as easy as you would think no it's not it's not sorry i'll stop editorializing okay
00:19:20
Speaker
But once you check those things, you're then going to consider, is it really more dyspnea that's the problem or are they having exacerbations? Because that's going to determine how you adjust their therapy. So if it's dyspnea, then if they're on a monotherapy, you're going to switch them to combo therapy with a lava and llama.
00:19:44
Speaker
If they're already on a lava in llama, then sometimes you want to switch, just try switching to a different inhaler device with maybe different similar medications in it because people are going to respond differently to each one. If you tried that and they're still not getting better, then you probably need to investigate other potential causes of dyspnea, things like heart failure and such.
00:20:09
Speaker
If their problem is primarily exacerbations, then if they're on monotherapy, you want to check their blood eosinophils, good old eosinophils. If they're less than 300, you go to that lab-a-lama combination. But if they're greater than or equal to 300, that's the time to just jump right up to triple therapy.
00:20:29
Speaker
If they're already on a laba and llama and you would then reassess their eosinophils, if they're less than 100, then you're not going to add the inhaled corticosteroid because they're just not likely to benefit and they're just going to be exposing them to pneumonia risk at that point. So that's the time you probably would look to other things like riflumalast or azithromycin.
00:20:52
Speaker
But if they're greater than 100 or equal to 100, then that's that group that might still benefit from adding an inhaled corticosteroid. So you would be jumping up to triple therapy. Right.
00:21:04
Speaker
And you also mentioned earlier about de-escalation of steroids. So if they're starting to have recurrent pneumonias or if side effects become an issue, you can always de-escalate the steroid, but you just need to be aware that for those patients that have those high ESNFL counts over 300, that de-escalation is associated with an increased frequency of exacerbation. Right, yes. And I try to make that very clear to the residents that
00:21:35
Speaker
It's not as simple as you just change them over and you take the steroid away and then you see them back in three to six months. You really need to educate the patient because that is well documented that you could actually cause, you know, initiate another exacerbation and that's not what we want. No, we don't.
00:21:52
Speaker
So listeners, as primary care physicians, it seems that we need to get a lot more comfortable with the idea of checking eosinophils and prescribing triple therapy in our COPD patients.
Survival Benefits from IMPACT and ETHOS Trials
00:22:05
Speaker
And you know, when it comes to triple therapy, we talked about the effects on exacerbations, but Sandy, you mentioned earlier about a mortality benefit as well. That is correct. So prior to this data, no medication for the treatment of stable COPD showed improved survival.
00:22:20
Speaker
It was only non-pharmacologic. And I know we all remember the in-training exams in residency. I'll remember your boards. It was oxygen supplementation, smoking cessation, and pulmonary rehab. Those are the non-pharmacologic staples of treatment for COPD.
00:22:36
Speaker
And it was a joke with the residents and I that when in doubt, if it's a COPD question, the answer is always pulmonary rehab. And I'm not saying that that's not true, but I remember the first time I got the in-training exam answer incorrect because I think I had picked, of course, a drug as a pharmacist.
00:22:56
Speaker
The answer is usually pulmonary rehab. However, we do have two studies that have confirmed statistical significance with regards to overall mortality. You have the IMPACT trial and the ETHOS trial. These were both 52-week randomized control trials.
00:23:12
Speaker
Both of them had between 10,000 and 8,000 COPD patients. And the purpose of this study was to compare triple therapy with either a llama-laba combination or an ICS-laba combination. So, one of the studies was your all your once daily regimens with fluticasone, umiclidinium, and valanterol. And then the Etho study was the budessin-I and glycopyrilate for motorol combinations.
00:23:41
Speaker
Both of these were funded by pharma. There's no doubt about that. And so we always, you know, tend to question that even more. But the large patient size, you know, patient size and the enrollment and looking at the numbers, it's really pretty impressive. So I'm just going to try to summarize in general what the populations were, just so you know, like, does this apply to my patient population? And I can say for Cabarrus family medicine, it definitely applies.
00:24:06
Speaker
The average age was 65, 60% were males, 40% were current smokers. The mean COPD assessment score at baseline is 20. So think about that. These are your patients that have a lot of symptoms and that are impacted, okay?
00:24:21
Speaker
And all of them in the study had a history of moderate to severe exacerbations in the last year. And 20 to 25% of these patients were in the severe category. So again, this is not the population that, okay, this is your first visit for your diagnosis of COPD. Usually not. These are going to be patients that are a little farther down the road, okay? The primary endpoint of both trials was the rate of moderate to severe exacerbations.
00:24:46
Speaker
and moderate was defined as antibiotics or systemic steroids, and severe was defined as hospitalization or death. So in that primary endpoint, triple therapy was found to be superior compared to either the llama-laba combination or the ICS-laba combination in both trials. So triple therapy is the way to go in this patient population.
00:25:08
Speaker
very symptomatic sick patients. The secondary endpoint, which is kind of standard for most studies these days, included all-cause mortality, which is defined as time to death. And when they looked at that and compared it with dual lama lobotherapy,
00:25:24
Speaker
The impact hazard ratio, so the triple therapy with your fluticasone, triple therapy, that the hazard ratio was 0.72 and had confidence interval that did meet statistical significance. In the Etho study, which was the Budestinide study, the hazard ratio was 0.51. And again, the confidence interval was statistically significant. So now with both of these, we can
00:25:48
Speaker
say that there is a decrease in all-cause mortality. So it's pretty big news. It's going to change the board exam questions, right? Super exciting. Yeah, but as exciting as it is, there's always downsides. So what are the downsides to triple therapy?
Risks and Costs of Triple Therapy
00:26:02
Speaker
Yes.
00:26:03
Speaker
Adverse effects and cost, okay? So we'll go with adverse effects first. We've talked about pneumonia several times, but pneumonia is significantly higher with triple therapy compared to bronchodilator-only therapy. So this is also true with the ICS lobotherapy for COPD patients.
00:26:19
Speaker
Just to give you some numbers, the rates of pneumonia in the Etho study was 4% when a steroid component was on board versus 2% when it was only bronchodilator therapy. And in the Impact study, it was 8% versus 5%. So it is clinically significant as well as being statistically significant with the amount of pneumonia.
00:26:41
Speaker
We also can't dismiss hoarseness, cough, candidiasis. It's not uncommon. It's always linked to the steroid component, even with proper adherence. Again, don't knock it until you've tried to be that patient and that perfect patient. It's really hard. Pharmacists are always trying to counsel on proper technique and rinsing your mouth after each use, but life is hard and we're busy and we forget things and it's just hard to follow all that.
00:27:05
Speaker
And, of course, we talk about cost and just the problems with that. All of these inhalers are expensive. They're all expensive. They're all very expensive. I don't know what you categorize as expensive and very expensive. But, you know, when I'm saying the brand name is Trilogy and Brestree, there's, you know, $600 a month when you look at GoodRX. It's not really that important because whether it's $500 or $600, who's going to pay it, okay? I don't know what your number is.
00:27:31
Speaker
And for comparison, when you look at Cialto and Inoro, they're $500. I mean, they're all expensive. So we have to get creative. We have to use our resources. You have to look at coupons. You have to look at patient assistance programs, which, you know, for these branded products are exceptional. You have to have a team that can help you find the best regimen for that patient. And sometimes we have to get a little creative and we have to do other combinations and do what we can. So we've all been there and we know.
00:28:00
Speaker
Yeah, I feel like it's getting better though. I haven't had too many patients with having trouble getting those covered. You know, uh, the coupons are great, but again, you can't use them when you have, you know, state insurance like Medicare or Medicaid, but, um, but yeah, I think it's gotten a lot better and hopefully we'll continue to as we, uh, see more, more and more, uh, evidence showing that these are beneficial.
00:28:21
Speaker
Yes.
Summary of Guideline Changes and Triple Therapy Importance
00:28:23
Speaker
So wrapping up, it seems that we have a few key takeaways from the 2023 gold guidelines update. So first, Laba ICS is out. Triple therapy is in. So in patients with frequent COPD exacerbations, you want to consider triple therapy, especially if they have ESNFLs of 300 or higher.
00:28:43
Speaker
But you want to beware if they have a history of repeated pneumonia, history of mycobacterial infection, or again, if they have ESNFLs less than 100. Number two, triple therapy is the only pharmacological intervention for COPD with an associated mortality benefit. You can bet that's going to be on a board exam coming up soon. I think so. Number three, ABCD table is gone. It is now A, B, E.
00:29:10
Speaker
So be sure that you are doing a formal symptom assessment like the MMRC or the CAT, the COPD assessment test. And then finally, more patients now are getting the llama-lava combination at start than previous guidelines. And now we're using it for all group B
00:29:28
Speaker
and group E patients. That is correct. You get an A plus for the day, Bobby. Well, thank you, Sandy, for being here. I think this is like the third time we've tried to record this. We've just had some technical difficulties. We're just amateurs at this podcasting thing. Dawn was on the original recording that messed up and so she couldn't be here for this one. So we miss her.
00:29:58
Speaker
I know. Sorry, Dom. Next time. But anyway, that's all for today's episode.
Feedback and Listener Engagement
00:30:04
Speaker
You can find show notes and appropriate links to the studies in the episode description. Just want to thank all our loyal listeners. We are now heard in over 35 countries. Can you believe that? No, I cannot.
00:30:16
Speaker
So if you have any thoughts on the show or if there is anything that we said that was just blatantly wrong and you feel we need to know about that, please let us know on Twitter. We can be found at the proof podcast or email us at whatstheproofpodcastatemail.com and we'll see you next time.