The rapidly evolving field of COPD

Another highlight at the Irish Thoracic Society Annual Scientific Meeting was a virtual lecture from internationally recognised Prof Fernando Martinez, Chief of the Division of Pulmonary and Critical Care Medicine at the Weill Cornell Medical College, New York, US. In the lecture the area of  chronic obstructive pulmonary disease (COPD) was described as a “dramatically, rapidly evolving field to be involved in”. During his presentation, entitled ‘COPD: How biological understanding is altering our approach to diagnosis and management’, Prof Martinez provided an overview of some of the most recent changes in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 recommendations; insight into the pathophysiology and research underpinning the changes; and a preview of the innovative treatments that “are coming down the line” thanks to developments in biologics and advanced understanding of the disease.  

Prof Martinez, who is a member of the GOLD science committee, began by describing the ongoing challenges in defining COPD. He acknowledged the various manifestations of the condition, such as young COPD, late COPD, and pre-COPD, that make a definition even more difficult to achieve. “We are continuing to revise the definition,” he said. However, he said that “airflow obstruction has not changed” as a defining feature of the condition.

Attendees then received an account of the new “population of COPD as defined by their clinical picture and biological marker”, as Prof Martinez described the transition from the ABCD combined assessment tool to the new ABE tool in the GOLD 2023 document. He explained that the A and B groups remain unchanged, but the C and D groups have been merged into a single E population to highlight the “importance of exacerbations in the assessment of a patient with COPD”.

Continuing with the “series of substantial changes in recommendations” from GOLD, including those related to dual bronchodilation and inhaled corticosteroids, Prof Martinez explained that “better understanding of the inflammatory picture in a COPD patient has influenced our approach”. He also emphasised that the data regarding eosinophils has had “a very practical implication for how we treat patients with COPD”. He went on to summarise findings from major studies, including the IMPACT and ETHOS trials, that found triple therapy of inhaled corticosteroid, long-acting muscarinic antagonist (LAMA), and long-acting b2-agonist (LABA) given in a single inhaler to be superior to dual bronchodilation. “In both studies, there was also an improvement in all-cause mortality,” Prof Martinez said.

Moving on to examine some of the “tremendous work occurring in COPD”, Prof Martinez presented the empirical evidence supporting biologics like dupilumab and itepekimab in the management of the disease, and the advances in scientific understanding of many signalling and inflammatory pathways involved in COPD. The room heard about a range of “targeted therapeutic approaches to downstream or upstream signalling pathways for inflammatory responses” that will be available in coming months, and have the potential to transform COPD management and patient outcomes. “What we will be doing next year will be very different from now,” Prof Martinez said in conclusion.