Tests May Help Predict COPD Flare-Ups

Three low-cost blood tests may help to predict flare-ups of a serious lung disease, a new study finds. The study focused on a medical database of 61,000 people. All had chronic obstructive pulmonary disease (COPD). This disease is a combination of chronic (long-lasting) bronchitis and emphysema. The vast majority of COPD patients are smokers or ex-smokers. Some people with the disease have flare-ups. These are periods of more intense symptoms. People in the study were not having flare-ups at the time the study began. They were given blood tests that looked for 2 proteins: fibrinogen and C-reactive protein. Another test measured a type of white blood cell called leukocytes. People who had increased levels of all 3 were more likely to have frequent flare-ups during a follow-up period. The Journal of the American Medical Association published the study. HealthDay News wrote about it June 11.

By Howard LeWine, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

Lung cancer is the most recognized severe health condition caused by smoking. Indeed, it is the leading cause of cancer death.

But another smoking-related disease causes more disability, more days in the hospital and almost as many deaths as lung cancer. The disease is COPD, chronic obstructive pulmonary disease.

COPD includes chronic bronchitis and emphysema. More than 80% of people with COPD are current or former smokers. Most are over age 40. Women are more likely to develop it than men. The reason isn't known, but it is not because women smoke more. The gap has narrowed, but women still smoke less than men.

The main features of COPD are:

• Less flow of air into and out of the lungs
• Permanent damage to the lungs and bronchial tubes
• Symptoms that usually get worse over time

Many people with COPD also go through flare-ups. Doctors call them COPD exacerbations. Typical symptoms of a flare-up include:

• Increased coughing
• Change in the color of coughed-up mucus
• Increased shortness of breath
• Fatigue
• Wheezing

Compared with COPD patients who have few or no flare-ups, those with frequent flare-ups:

• Lose lung function at a faster rate
• Score lower on quality-of-life measures
• Die sooner

Identifying people with COPD who are more likely to have flare-ups could lead to better treatments to prevent them.

Previous studies have shown that having one flare-up is the best predictor of more flare-ups. And it's known that people with more severe COPD tend to be at higher risk of flare-ups. But some people with mild or moderate COPD also get flare-ups. And not everyone with severe COPD has them.

Flare-ups happen because the lungs' airways get infected, inflamed or both. Once a flare-up starts, the white blood cell count and blood levels of certain proteins rise in response. These changes can be measured by blood tests.

Could these same tests predict flare-ups before they happen?

This study tried to find out. The researchers looked at three simple, low-cost blood tests. The tests measure C-reactive protein (CRP), fibrinogen and the white blood cell count.

If all three tests were abnormally high when patients were stable, the patients were likely to have a flare-up. If all three tests were within the normal range, a flare-up was not likely to occur.

Should everyone with COPD get these blood tests? No, because it wouldn't change the general treatment advice for most patients with COPD.

However, for someone who is still smoking or not sticking with treatments, the blood tests might be worthwhile. If all three tests were abnormal, it might motivate the person to take action.

What Changes Can I Make Now?

If you have COPD and still smoke, you really must quit now. Quitting smoking is the only chance you have to prevent the disease from getting worse.

Drugs for COPD cannot slow down the eventual decline in lung function. However, they can allow people to breathe a little easier, with less coughing. They also help prevent COPD flare-ups.

Commonly used drugs for COPD help people in different ways:

• Corticosteroid inhalers reduce inflammation.
• Beta-agonist inhalers improve air flow by relaxing the airways. Some inhalers combine a long-acting beta-agonist with a corticosteroid. These include Advair and Symbicort.
• Anticholinergic inhalers also improve air flow. They have a different way of relaxing bronchial tubes. One of the most popular inhaled drugs used to treat COPD is tiotropium (Spiriva).

What Can I Expect Looking to the Future?

Most COPD flare-ups start with an infection in the bronchial tubes. Therefore, an antibiotic is usually part of the treatment when a flare-up occurs.

Recent studies have looked at whether a daily antibiotic could prevent COPD flare-ups. Results have been mixed. However, it does appear that taking the antibiotic azithromycin every day can help prevent flare-ups in some COPD patients. But there are side effects, such as a risk of hearing loss.

It would be helpful to identify which patients would get the most benefit from taking daily azithromycin. Perhaps future studies will show whether this strategy is most effective for stable COPD patients with high levels of CRP, fibrinogen and white blood cells.