Moving Towards Patient-Centered Medicine for COPD Management: Multidimensional ApproachesversusPhenotype-Based Medicine—A Critical View

Abstract

For decades, chronic obstructive pulmonary disease (COPD) has been considered a relentlessly progressive disease in which the deterioration of lung function is associated with an increase in symptoms, interrupted only by periods of exacerbation. However, this paradigm of COPD severity based on FEV1 has been challenged by currently available evidence. So far, three main approaches, though with contradictory aspects, have been proposed in order to address the complexity of COPD as well as to develop appropriate diagnostic, prognostic and therapeutic strategies for the disease: 1) the use of independent, clinically relevant variables, 2) the use of multidimensional indices, and 3) disease approaches based on clinical phenotypes. Multivariable systems seem superior to FEV1 in predicting prognosis and defining disease severity. However, selection of variables available from current literature must be confronted with issues of medical practice. Future evidence will be needed to reveal their effective relationship with disease long-term prognosis and to demonstrate the most adequate cutoff values to be used in clinical settings. Multidimensional scores provide a good prognostic instrument for the identification of patients with a particular degree of disease severity. Clinical phenotyping can help clinicians identify the patients who respond to specific pharmacological interventions; however, there is some controversy about the phenotypes to select and their long-term implications. Although these approaches are not perfect, they represent the first step towards patient-centered medicine for COPD. In the near-future, these different approaches should converge towards one new field to focus on the better management of COPD patients.

Introducing COPD Research and Practice

“…The interrelationships between all aspects of the disease (e.g. genetic, biological, environmental, clinical, social) will surely offer new possibilities to converge towards a new focus on COPD management that aims at personalized treatment, challenging and overcoming the classical concepts of the disease [9]. Unfortunately this approach, although extremely appealing, is still in its infancy.…”

Prioritization of COPD protein biomarkers, based on a systematic study of the literature

“…Interesting challenges in current COPD medicine include developing tools that allow optimizing therapeutic interventions following the shift of a general COPD treatment towards a more personalized, patient-centered medicine [10,11] . For example, biomarkers that would support decisions such as the use of bronchodilators and/or inhaled corticosteroids [12][13][14] ,…”

“…are of outmost interest in order to select the most adequate treatment option for each patient [11] . Furthermore, the prediction of lung function decline amongst COPD patients and therefore development of biomarkers that enable differentiation of slow and fast decliners, would be of importance in developing early stage treatments for particularly the fast decliners as well as in understanding the mechanisms that are involved in the progression and severity of COPD [15][16][17][18][19] .…”

Copd phenotype — the way to personalized medicine ХХI century

“…Согласно принципам современной персонализи-рованной медицины [21,28,29,31,32] клинические фенотипы должны учитываться при лечении пациен-тов, фенотипирование может помочь практикующе-му врачу прогнозировать реакцию пациента на фар-макологическое вмешательство и является началом пути к лекарствам, ориентированным на конкретно-го пациента [33]. В настоящее время усилия фарма-кологов направлены на создание новых комбинаций фиксированных доз бета2-агонистов продолжитель-ного действия (LABA) с ИГКС, LABA с пролонгиро-ванными антагонистами мускариновых рецепторов (LAMA), разрабатываются «тройные» ингаляторы, бифункциональные соединения, обладающие эф-фектами мускаринового антагониста и агониста бе-та2-адренорецепторов (МАВА), новые ингибиторы фосфодиэстеразы 4, целевые «таргетные» противо-воспалительные и иммунотропные препараты.…”

“…В настоящее время усилия фарма-кологов направлены на создание новых комбинаций фиксированных доз бета2-агонистов продолжитель-ного действия (LABA) с ИГКС, LABA с пролонгиро-ванными антагонистами мускариновых рецепторов (LAMA), разрабатываются «тройные» ингаляторы, бифункциональные соединения, обладающие эф-фектами мускаринового антагониста и агониста бе-та2-адренорецепторов (МАВА), новые ингибиторы фосфодиэстеразы 4, целевые «таргетные» противо-воспалительные и иммунотропные препараты. Эф-фекты этих препаратов во многом зависят от фе-нотипа ХОЗЛ [32][33][34]. Высказывается мнение, что современные методы лечения не способны ликви-дировать воспаление, предупредить прогрессирова-ние болезни, снизить смертность [32].…”