Novel Advances and Concepts (NAC) in Respiratory Medicine: Reframe, Rethink and Refresh

Chronic obstructive pulmonary disease (COPD) continues to be an impactful clinical entity worldwide. Owing to the complexity of its pathogenesis and the growing knowledge surrounding the disease, the approach and management of COPD continue to evolve. Recent studies have identified treatable traits in COPD patients as therapeutic targets which allow for a more personalized treatment approach. And amidst the ever-evolving landscape of COPD management, one molecule, N-acetylcysteine (NAC) remains relevant, with growing evidence supporting its utility and clinical efficacy.

This was the focus of discussion during the recent scientific summit entitled Novel Advances and Concepts (NAC) in Respiratory Medicine: Reframe, Rethink and Refresh held last July 6, 2023, at the Grand Hyatt Hotel, BGC, Taguig City. The event - made possible by a partnership between Cathay Drug Company Incorporated (CDCI), Zambon Pharmaceuticals and MIMS Philippines - gathered today’s most influential local and international key opinion leaders in respiratory medicine and was attended by pulmonologists from all over the country.

The event was formally opened by Dr Rogelio Garcia, CDCI Medical Director, who adeptly turned on the reframe, refresh and rethink mode of the attendees to pave the way for the scientific sessions.  



Treatable Traits
Dr Jubert Benedicto, pulmonary critical care specialist and associate professor at the UP College of Medicine, chaired the morning session that explored the science behind the treatable traits approach. The discussions started off with an interactive presentation jointly delivered by Dr Lenora Fernandez, head of the division of pulmonary medicine at UP-PGH, and Dr Patrick Moral, an active consultant of pulmonary and sleep medicine at the University of Sto. Tomas. In their discussion, they acknowledged the heterogeneity of the signs and symptoms among COPD patients¹ and how limiting the clinical approach to guideline recommendations may in turn limit the management to a linear approach.² The speakers encouraged the attendees to rethink the strategy to COPD diagnosis and treatment and introduced the concept of treatable traits in the context of COPD. Chronic mucus hypersecretion was highlighted to be among the potential targets to treat that is commonly seen in patients with COPD.³ It was also emphasized that the treatable traits approach is congruent with the current prevailing GOLD guidelines for COPD.⁴

The session got more interesting as the attendees listened to the reactions from Dr Josephine Ramos and Dr Albert Santos. Doctor Ramos, chair of the asthma council of the Philippine College of Chest Physicians and instrumental in crafting the current asthma treatment guidelines, highlighted the benefits and possible challenges that may be encountered in developing guidelines centered around the treatable traits. On the other hand, Dr Alberto Santos, a consultant pulmonologist practicing at multiple centers in Cebu, Philippines, covered the pros and cons of the approach from the point of view of a local clinician. Their joint discussion added deep insight into the implementation of treatable traits and its integration into the guidelines for COPD management in the local setting.

The symposium’s international guest lecturer was Professor Ian Pavord of the UK’s University of Oxford, who is best known for his scientific publications that helped shape the present landscape of respiratory medicine. He discussed the limitations of prevailing guidelines and raised the need for recommendations and studies that not only specify the efficacy and safety of treatment but also identify patient profiles for whom each regimen would be most beneficial,⁵ alluding to the advantages of the treatable traits approach. He wrapped up his discussion by stating that the treatable trait approach is feasible even at the primary care level and that focusing on mucus hypersecretion and other traits may be timelier.



N-acetylcysteine (NAC)
The afternoon session chaired by Dr Patrick Moral focused on N-acetylcysteine, the enduring molecule whose clinical efficacy and safety profile has remained relevant throughout the recent developments in respiratory disease management. In the first lecture, Doctor Aileen Wang, past president of the American College of Chest Physicians CHEST Philippine delegation and Professor V at the UP College of Medicine detailed the central role of oxidative stress in the pathogenesis of COPD.⁶ Further, she illustrated the instrumental role of NAC in addressing the vicious cycle of changes in COPD, thereby improving patient outcomes.⁷ She ended her discussion by providing evidence on the efficacy and safety of NAC, citing landmark studies such as the PANTHEON study and other meta-analyses.⁸

The final lecture delivered by Dr Camilo Roa, global governor of the American College of Chest Physicians, touched on the complexity of the pathogenesis of COPD, and how it co-exists with other chronic pulmonary diseases that are prevalent locally, further compounding the burden borne by patients. At the same time, he acknowledged lung disease heterogeneity, highlighting the need to identify and target treatable traits in COPD patients.⁹ In closing, Dr Roa put out a call to action to build confidence among healthcare workers to embrace the treatable traits approach in the context of respiratory medicine.

To wrap up the scientific session, Dr Jubert Benedicto discussed the current knowledge gaps surrounding the treatable traits approach, ongoing research on NAC including a nebulized form,¹⁰ and what needs to happen to move towards effective implementation of the treatable traits approach.

Conclusion
With the attention surrounding chronic respiratory diseases and the rapid pace by which knowledge is accumulated in the field of respiratory medicine, scientific sessions such as the recently concluded NAC forum are vital in ensuring that these updates are cascaded to healthcare practitioners to empower them to continue to provide quality and timely care and further elevate respiratory medicine locally. In his closing message, Stephen Gan, CDCI Vice President, expressed the company’s gratitude for the opportunity to be at the forefront of what could be a pivotal milestone in respiratory disease management.