Identifying, treating patients with COPD plus diabetes, COPD plus osteoporosis

Key takeaways:

• A 2013 study found that 55% of 213 patients with COPD reported diabetes and almost 40% reported osteoporosis.
• Clinicians can catch osteoporosis early by reading chest CT scan reports.

PHILADELPHIA — In addition to COPD, patients frequently have other chronic diseases on top of their lung disease, including type 2 diabetes and osteoporosis, according to a presentation at the 2024 GOLD COPD International Conference.

“We want to approach COPD as part of a multimorbid condition for each patient,” Kristin E. Criner, MD, associate professor of medicine at Lewis Katz School of Medicine at Temple University, said during her presentation. “We want to shift from a single-disease approach to a person-centered, holistic, integrated approach.”

According to Criner, the average number of chronic diseases in this population is five, with occurrences commonly “undiagnosed or misdiagnosed and unmanaged or mismanaged.”

“COPD is a single disease with multiple comorbidities,” Criner said. “They affect the cardiovascular system, the brain, the musculoskeletal system, the bone, as well as the gut.”

Criner explained that these additional chronic diseases are likely due to syndemics.

“These are occurrence of disease clusters with shared risk factors and biological interactions,” Criner said. “These exacerbate the prognosis and burden of disease on individuals and society.”

Delving into endocrine-related comorbidities in the context of COPD, Criner shared results of a 2013 study published in American Journal of Respiratory and Critical Care Medicine that found that 55% of 213 patients with COPD self-reported diabetes, almost 40% reported osteoporosis and about 25% reported obesity.

When describing patients suffering with both COPD and diabetes, Criner noted some frequent characteristics, including GOLD groups 3 to 4, which represent more severe COPD, as well as poor clinical outcomes.

Patients with this disease combination who receive GLP-1 agonists have demonstrated improvement in lung-related outcomes, such as exacerbations, mortality and airway inflammation, according to Criner.

As Healio previously reported, use of GLP-1 agonists or co-agonists in patients with COPD and type 2 diabetes was associated with a lower risk for all-cause mortality and several respiratory outcomes, including incident COPD exacerbation, vs. other type 2 diabetes medications.

Adding onto this evidence, Criner highlighted that a population-based cohort study published in BMJ in 2022 found a lower cumulative incidence of severe COPD exacerbations among patients with COPD and type 2 diabetes receiving GLP-1 receptor agonists (liraglutide, lixisenatide, semaglutide, dulaglutide or exenatide) vs. sulfonylureas.

In the context of COPD, there are several proposed mechanisms on how GLP-1 receptor agonists work, Criner said.

“They are thought to reduce local inflammation and airway hyperresponsiveness,” Criner said. “They [also] are thought to have systemic anti-inflammatory effects on smoking, obesity and hypertension. They improve surrogate measures of lung function, such as FVC, and there’s a reduction in visceral adiposity.”

In addition to knowing the benefits of diabetes medications s in patients with COPD and diabetes, clinicians should also know the side effects frequently reported with use of these drugs. Criner outlined the following side effects during her presentation: nausea, constipation, diarrhea, early satiety and weight loss.

Further, an elevated risk for hypoglycemia has been observed with basal insulin, sulfonylureas and meglitinides, and contraindications have been found in medullary thyroid cancer and pancreatitis, Criner said.

As noted above, osteoporosis is another disease that impacts patients already suffering with COPD.

“Most of the time, patients are asymptomatic and often undiagnosed until fractures occur, which can make treatment very difficult,” Criner said.

“[Osteoporosis] causes deteriorating lung function,” Criner added. “Each vertebral fracture decreases the FVC by 9%.”

To help alleviate these patients, it is important to catch osteoporosis early, and this can be done by reading chest CT scan reports, Criner said.

“If you are able to, order a DEXA or refer to an endocrinologist or primary care doctor because screening is very key,” Criner said.

In terms of treatments for this disease combination, Criner emphasized using calcium and vitamin D supplements; modifying unhealthy behaviors; and using pulmonary rehabilitation and physical therapy.

“Aerobic exercises increase the [bone mineral density], and then really important is the combination of resistance and balance training,” Criner said.

Additionally, medications for these patients include bisphosphonates, anabolic therapy and selective estrogen receptor modifier therapy, according to Criner.

“Both type 2 diabetes and osteoporosis are prevalent co-morbid conditions in COPD,” Criner said. “Early detection, identification and treatment are key.”

References:

• Pradhan R, et al. BMJ. 2022;doi:10.1136/bmj-2022-071380.
• Vanfleteran LEGW, et al. Am J Respir Crit Care Med. 2013;doi:10.1164/rccm.201209-1665OC.