Flu this Winter 2016-17: Important Treatment Information

What Should I Do if I get the Flu this Winter?

Dear Dr. Mahler:

I am concerned about what to do if I get the flu this season. My doctor has told me my COPD is severe, but I am doing pretty good. I use Anoro in the morning, and have Combivent as my rescue inhaler. I try to walk or do some activity every day depending on the weather. However, I worry about the flu this winter, and how I might get very sick. What is your advice?

Cecilia from Salinas, CA

Dear Cecilia:

Signs and symptoms of the flu

People who have the flu often feel some or all of these signs and symptoms:

  • Fever or feeling feverish/chills
  • Cough
  • Sore throat
  • Runny or stuffy nose
  • Muscle or body aches
  • Headaches
  • Fatigue (feeling tired)

 

How Flu Spreads

People with the flu can spread it to others up to about 6 feet away. Flu viruses spread mainly by droplets made when someone with flu coughs, sneezes, or talks.  A person might also get flu by touching a surface or object that has flu virus on it and then touching her or his mouth, eyes or possibly their nose.

Coughing can expel the virus and cause flu this winter

Man coughing flu virus into the air.

When is Flu Contagious?

The flu can be passed to someone else before you even know you are sick as well as when you are sick. Most adults are able to infect others starting 1 day before symptoms develop and up to 5 to 7 days after becoming sick. Some people, especially those with weakened immune systems, might be able to infect others for an even longer time.

When do flu symptoms start?

The average time is 2 days from when a person is exposed to flu virus to when symptoms begin. However, the range is 1 to 4 days.

How to prevent getting the flu?

You should stay away from sick people. Wash your hands often with soap and water, or use an alcohol based hand rub. Avoid touching your mouth, nose, and eyes with your hands.

Certainly, it is important to get the flu vaccine. If you haven’t received it yet, make sure to the shot as soon as possible.

Can the flu be treated?

Tamiflu capsules for treating flu symptoms

 

There are prescription medications  called antiviral drugs for treating the flu this winter. Since you have COPD, you are considered in the high risk group. Contact your health care provider as soon as symptoms start. Tamiflu is an antiviral pill that is used to treat acute, uncomplicated illness due to influenza A and B infection if you have symptoms of the flu for less than 48 hours.

When used for treatment, antiviral drugs can lessen symptoms and shorten the time you are sick by 1 or 2 days. They also can prevent serious complications like pneumonia.

Complications of the flu

Sinus and ear infections are examples of moderate complications from flu, while pneumonia is a more serious complication that can result from either influenza virus infection alone or from co-infection of flu virus and bacteria. Other possible serious complications triggered by flu can include inflammation of the heart, brain, or muscle tissues.

I hope that this information is helpful. Be safe and stay healthy.

Donald A. Mahler, M.D.

Recurrent Chest Infections due to Acquired Immunodeficiency

Recurrent Chest Infections – Need to Test Immunoglobulin Levels

Background: Recurrent chest infections in those with COPD can cause coughing, chest congestion, shortness of breath, and “feeling sick all of the time.” These symptoms may improve with courses of antibiotics and prednisone, but may recur weeks after these medications are stopped.

One possible cause for repeated chest infections is a low level of antibodies.

Plasma cells, which are part of the body’s immune system, makes antibodies to fight off bacteria, viruses, and other invaders that could harm overall health.

The body makes several types of immunoglobulin antibodies called A, G, and M. They are abbreviated as IgA, IgG, and IgM. IgA is found at high levels in saliva, tears, and nasal secretions. IgG is found in blood and in tissue, while IgM is found in blood.

In some individuals, plasma cells do not produce normal levels of antibodies. This medical condition is called common variable immunodeficiency (abbreviated CVID). It is estimated that CVID occurs in one out of 50,000 individuals in North America.

Case Report: I recently saw a 69 year old female in my practice who was referred for repeated episodes of pneumonia. She reports five different times she was sick with pneumonia in the past 11 months. Main symptoms are cough which may or may not be productive of mucus, more shortness of breath, feeling tired, and low grade fever. Recent x-rays of the chest showed shadows in the right lower lung area. For each episode her primary care physician prescribed an antibiotic and higher doses of prednisone.

She also has severe COPD based on results of breathing tests. She smoked one and one-half packs of cigarettes per day for 35 years, but quit 9 years ago. She did not report any heartburn symptoms to suggest possible acid reflux.

As part of her evaluation, I ordered blood tests to measure levels of immunoglobulins. Her IgG level was below normal, while IgA and IgM levels were in the normal range. I made the diagnosis of  common variable immunodeficiency and ordered: a CT scan of the chest to look for bronchiectasis; and replacement therapy with IVIG (immunoglobulin G).

Discussion: CVID was reviewed recently in the November-December 2016 issue of the Journal of Allergy and Clinical Immunology: In Practice (volume 4, pages 1039-1052). Usually, the person has recurrent sinus and/or chest infections. In the lungs, these repeated infections can cause thickening of the walls of breathing tubes and damage air sacs which creates a reservoir for bacteria (bronchiectasis) as shown in the figure below.

Figure C (bottom right) shows bronchiectasis with mucus inside the breathing tube and thickening of the wall.

Figure C (bottom right) shows bronchiectasis with mucus inside the breathing tube and thickening of the wall.

To diagnose CVID, your health care provider should measure levels of immunoglobulins (IgA, IgG, and IgM) in blood.

Replacement therapy is available if a person has a low level of IgG. The goal is to increase blood levels of IgG to normal to prevent future sinus and respiratory infections. Treatment is given intravenously (through an arm vein) every 4 weeks. This can be done at home or in an infusion center at the hospital. Studies confirm that IgG replacement reduces infections in those with CVID.

Cystic changes in the lungs due to bronchiectasis.

CT scan of the chest shows cystic changes in the lungs due to bronchiectasis.

If the person also has bronchiectasis, it is important to obtain a sample of sputum to identify the specific type of infection. Antibiotic therapy may be necessary for weeks to months.

Bronchiectasis Can Cause Frequent COPD Flare-ups

Bronchiectasis Is Linked to Increased Risk of a COPD Exacerbation

Background: Bronchiectasis is a chronic condition in which the walls of the breathing tubes are thickened from long-term inflammation and scarring. Typically, bronchiectasis is a result of a pneumonia which damages parts of the lung. As a result of the damage, mucus produced by the cells lining the breathing tubes does not drain normally. Mucus build-up can lead to a chronic infection. A cycle of inflammation and infection can develop, leading to loss of lung function over time.

CT scan shows cystic bronchiectasis

A slice of the chest on a high-resolution CT scan in a 62 year old with cystic bronchiectasis. The cysts are seen on the lower portions of both lungs.

Different types of bacteria and mycobacteria can infect the damaged areas of the lung causing:

  1. chronic coughing
  2. coughing up blood
  3. shortness of breath
  4. chest pain
  5. coughing up large amounts of mucus daily
  6. weight loss
  7. fatigue
  8. thickening of the skin under the finger nails and toes (called clubbing)

Poster Presention at CHEST meeting October 25, 2016, in Los Angeles: Dr. Kosmas of the Metropolitan Hospital in Piraeus, Greece, presented findings in 855 individuals with COPD 

42% of the patients were found to have evidence of bronchiectasis on CT scan of the chest. About 20% had experienced more than one flare-up (exacerbation) of COPD in previous year. The investigators also found that the severity of COPD predicted the increased likelihood that a person would have bronchiectasis.

Dr. Kosmas commented at the poster presentation that, “Bronchiectasis is an area in the lung that is destroyed by pneumonia, and bacteria reside there. It results in a low-grade infection, and can then lead to inflammation and an exacerbation.”

My Comments: The symptoms of bronchiectasis usually start off as mild with a persistent cough that produces yellow or green mucus. An antibiotic may help to clear up the mucus, but typically the yellow or green color returns after a few weeks.

A CT scan of the chest is important to diagnose this condition. Then, a fresh sample of the mucus should be obtained to send to the laboratory to identify the specific type of infection (sputum culture). Different blood tests should also be ordered to look for possible medical conditions that may contribute to bronchiectasis (for example, cystic fibrosis, immunodeficiency, HIV infection, alpha-1 antitrypsin deficiency, rheumatoid arthritis, and inflammatory bowed disease).

If you experience frequent chest infections, or continue to cough up yellow-green mucus persistently, ask you health care provider to consider bronchiectasis.

Reduced Exacerbations with Two Bronchodilators

11% Reduced Exacerbations with Dual Bronchodilators

Dear Dr. Mahler:

I recently read about the results of the FLAME study on a COPD website.  As I understand the post, two different bronchodilators were better for reducing flare-ups of COPD than Advair.  I am 59 years old and have had COPD for four years. My doctor started me on Advair Diskus when I was diagnosed along with ProAir as needed. I have been doing pretty good, but had pneumonia this past winter. Should I ask my doctor about the two bronchodilator combination instead of taking Advair? Thanks for your advice.

Sam from Boulder, CO

Dear Sam:

The results of the FLAME study were presented at the International Conference of the American Thoracic Society in San Francisco in May 2016 and published in the New England Journal of Medicine on May 15, 2016 (doi:10:1056/NEJMoa1516385). Dr. Jadwiga Wedzicha is the first author of the study.

The FLAME study was a head-to-head comparison of: ♦ two different types of bronchodilators [indacaterol – a long-acting beta-agonist and glycopyrronium – a long-acting muscarinic antagonist] – brand name is Ultibro AND ♦ a bronchodilator [salmeterol] and an inhaled corticosteroid [fluticasone] – brand name is Advair.

3,300 patients from 43 countries participated in the study. After one year, the rate of COPD exacerbations (“flare-ups”) was 11% lower with indacaterol-glycopyrronium compared with salmeterol-fluticasone. Patients who received the two bronchodilators also had better quality of life and used albuterol as rescue medication less frequently.

Dr. Wedzicha commented that, “I think we can say that . . . a dual bronchodilator is the first choice combination that can be used in patients with COPD.”

Sam – I suggest that you discuss these findings with your doctor. You should be aware that an inhaled corticosteroid medication (such as fluticasone as found in Advair) is associated with an increased risk of pneumonia. For this reason alone, it would be reasonable to stop Advair since you had pneumonia this past winter. The reduced exacerbations (flare-ups) with indacaterol/glycopyrronium (Ultibro) is another reason to consider a dual bronchodilator inhaler. At the present, Ultibro is not available in the US.

Anoro Ellipta dry powder inhaler

Anoro Ellipta dry powder inhaler

Stiolto Respimat delivers a fine mist.

Stiolto Respimat delivers a fine mist.

However, Anoro Ellipta and Stiolto Respimat are dual bronchodilators available in the US and are similar to Ultibro used in the study. Neither of these medications contain a inhaled corticosteroid.

 

Once again, I encourage you to talk to your doctor about the results of the FLAME study and ask her/him about replacing Advair with one of the two combination bronchodilators.

Best wishes,

Donald A. Mahler, M.D.

Inhaled Corticosteroids and Pneumonia

Stopping Inhaled Corticosteroids Reduces Pneumonia

Background: Inhaled corticosteroids are an inhaled form of prednisone which reduces inflammation. Inhaled corticosteorids are approved  by the US Food and Drug Administration (FDA) to treat those with COPD in combination with a long-acting beta2-agonist bronchodilator. The names of these medications are: Advair; Symbicort; and Breo.

Studies show that these medications make it easier to breathe and reduce the chances of an exacerbation (worsening of shortness of breath, increased coughing, and/or more mucus) usually due to a chest infection. However, there is an increased risk of pneumonia in those with COPD who use Advair, Symbicort, or Breo.

Study Findings: In the November 2015 issue of CHEST (volume 148; pages 1177-1183) Samy Suissa, Ph.D., and colleagues examined health insurance information in over 103,000 individuals with COPD who used inhaled corticosteroids in the Quebec province of Canada from 1990 through 2009. Some of these stopped thier use during the study period.

The main finding was that stopping inhaled corticosteroids was associated with a 37% decrease in the rate of serious pneumonia (either requiring hospitalization or death from pneumonia).

My Comments: Both you and your health care provider should consider expected benefits and possible risks of any medication that you take. The findings of this study highlight the concern of the increased risk of pneumonia in someone taking inhaled corticosteroids and shows a decreased risk when inhaled corticosteroids are stopped.

In my practice, I advise someone with COPD to stop the medication containing an inhaled corticosteroid IF he/she has had pneumonia. I caution the individual that stopping the medication may make their breathing worse, and make sure that the person is taking both classes of different bronchodilators to improve breathing.

As always, I encourage you to discuss your individual situation with you health care provider.

 

Pneumonia Vaccine

Dear Dr. Mahler:

I read about the new pneumonia shot, but am confused because my doctor gave me a pneumonia shot about 5 years ago. I am 68 years old and my COPD has been stable for the past few years. Each year I get the flu shot and walk almost every day when the weather is good. On bad weather days, I walk on my treadmill in the basement. What do you think about the new pneumonia shot? Should I get it?

Phil from Evansville, IN

Dear Phil:

Your question brings up a confusing topic for both patients and health care professionals. Streptococcus pneumonia is a bacteria that causes thousands of cases of bloodstream infections and pneumonia each year in the United States. This bacteria is also called pneumococcus. Although the peumococcal vaccine is very good at preventing severe disease, hospitalization, and death, it is not guaranteed to prevent infection and symptoms in all people. Also, remember that there are many different bacteria and viruses that can cause pneumonia.

The new pneumonia vaccine is called pneumococcal conjugate vaccine (abbreviated as PCV13; brand name is Prevnar 13®) and protects against 13 types, or strains, of pneumococcal bacteria. The older pneumonia vaccine is called pneumococcal polysaccharide vaccine (abbreviated as PPSV23; brand name is Pneumovax®) and protects against 23 types, of strains, of pneumococcal bacteria.

Here are the recommendations for the two pneumococcal vaccines according to the Centers for Disease Control and Prevention:

> PPSV23 is recommended for all adults 65 years and older and for adults 19 through 64 years of age who are at high risk for pneumococcal infection including those who have COPD.

> PCV13 (the newer vaccine) is recommended for all adults 65 years of age or older whether you have COPD or not. Those who have not previously received PPSV23 should receive a dose of PCV13 first, followed 6 to 12 months later by a dose of PPSV23. If you have already received one or more doses of PPSV23, the dose of PCV13 should be given at least one year after you got your most recent dose of PPSV23

You should not receive either pneumococcal vaccine if you had a severe allergic reaction after a previous dose or to a vaccine component.

Phil – since you received the PPSV23 vaccine about 5 years ago, you should ask your doctor about the getting the PCV13 vaccine for greater protection against the pneumococcal bacteria.

Sincerely,

Donald A. Mahler, M.D.