Asthma patients who smoke may benefit from COPD treatment

Key takeaways:

• Remodeling may include more smooth muscle mass and epithelial cell shedding.
• Macrolides, vaccination and pulmonary rehabilitation may help smokers.
• Varenicline is “the best option” for smoking cessation.

SAN ANTONIO — The lungs of patients with asthma who smoke begin to resemble those of patients with COPD, which may require changes in treatment, Brian Bizik, MS, PA-C, said at the 16th Annual Allergy, Asthma & Immunology CME Conference.

“They have lots of remodeling,” Bizik, immediate past president of the Association of PAs in Allergy, Asthma and Immunology and pulmonary care coordinator of Terry Reilly Health Centers in Boise, Idaho, said during his presentation.

These patients experience increases in smooth muscle mass, epithelial cell shedding, angiogenesis and subepithelial fibrosis, as well as increases in goblet cells, which make mucus.

“You get more clumping of the epithelial cells, more blood vessels in the tissue. It gets bigger, thicker, boggier,” he said. “You have this thickening and this fibrotic layer.”

Recommendations for treatment from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) may help, Bizik said.

“Maybe I’m not going to change your inhaler, but the GOLD guidelines will help me,” Bizik said. “Even though right now your diagnosis is asthma, I’m thinking that you may be more COPD-ish based on smoking.”

Clinicians with these patients could consider macrolides early and provide them longer, according to GOLD.

“Azithromycin is a workhorse for COPD. It works very well. I use it in lieu of steroids sometimes, or with steroids,” Bizik said.

Physicians also should focus on exacerbation prevention via vaccinations and pulmonary rehabilitation, which patients typically do not receive even though Cochrane Reviews have called it effective, Bizik said.

“You look at pulmonary rehabilitation, and Cochrane says ‘We recommend no further studies, because this is so good. We recommend no more studies comparing pulmonary rehab to not. Don’t do it anymore. It’s that good,’” Bizik said.

Nebulizer therapy should be considered as well since these patients have such a difficult time inhaling medicine due to poor manual dexterity, cognitive function or inhalation capacity, he continued.

Short-acting and long-acting beta 2 agonists and anticholinergics are available for nebulizers, as are short-acting beta 2 agonist and combinations.

“I’ve had really good luck getting these,” Bizik said. “I have people on triple inhalers, but it’s on a nebulizer that they do twice a day.”

Patients enjoy using the nebulizer too, he continued.

“It’s very soothing. It’s very rewarding,” Bizik said. “They know they’re going to get the medicine. They know it’s going to work.”

Smoking cessation also is essential to care, he said, adding that varenicline (Chantix, Pfizer) is more effective than nicotine patches and bupropion.

“Chantix is really the best option by far,” Bizik said. “Nothing else works.”

Compared with these other strategies, similar or fewer adverse events are associated with varenicline, even when patients have other psychiatric or substance abuse issues.

“It is a very good medicine if you’re worried about psychiatric issues,” Bizik said.

When people are trying to quit smoking, they “want to hit everybody, punch everybody and eat everything,” Bizik said. “Those are the side effects if you use Chantix or not. It doesn’t matter. It’s not worse.”

Finally, Bizik is not above having tough conversations with his patients either.

“I scare patients,” he said.

Bizik shares the results of pulmonary function testing with his patients, and he shows them their chest X-rays as well.

“Then I say, ‘So, just thinking about the future, are you somebody that you think you would rather carry your oxygen or pull it behind you?’” he said. “Then they take the Chantix prescription.”

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Brian Bizik, MS, PA-C, can be reached at brianbizik@yahoo.com.