Dr Stephen Child. General Physician Auckland. 14:20-14:40 Secondary Care Perspective

Transcription

1 Dr Stephen Child General Physician Auckland 14:20-14:40 Secondary Care Perspective

2 Wheeze Witchery Stephen Child MD, FRACP, FRCPC General Physician Respiratory Interest Director of Clinical Training Auckland District Health Board

3 Conflict of Interest Speaker Fees - AstraZeneca - Boehringer Ingelheim - Merck Sharp & Dohme - Pfizer - GlaxoSmithKline Chair New Zealand Medical Association Clinical Governance Group Procare PHO/Homecare Medical Treatment Injury Advisor - ACC

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5 Obstruction FEV 1.0 < 0.70 VC FVC 40% 1s

6 Obstructive Airways Diseases Asthma/COPD Bronchiectasis Allergic Bronchopulmonary Aspergillosis Cystic Fibrosis Sarcoidosis CHF Broncholitis- obliterans ( COP/other ) Allergy/Anaphylaxis Obesity?? Other- Eg: aspiration,fb,etc

7 Professor Peter J. Barnes, MD National Heart and Lung Institute, London UK

8 Inflammation in Asthma Acute inflammation Acute or chronic inflammation? Steroid response Chronic Inflammation Structural Changes Time Barnes PJ

9 GOLD 2011 subtypes CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease; mmrc, modified Medical Research Council questionnaire. GOLD, Global strategy for the diagnosis, management and prevention of COPD, Available at: (accessed February 2013).

10 Airflow Obstruction Asthma (Reversible) Eosinophils ICS responsive Neutrophils ICS unresponsive COPD (Non-Reversible)

11 COPD Controversy 1) When ICS? 2) EoS guided treatment? 3) Reduce exacerbation? 4) Which inhaler?

12 Guideline Summary Asthma COPD 1. SABA prn 2. ICS + SABA 3. ICS + LABA 4. Other 1. SA B.D prn 2. LA B.D 3. ICS if < 50% 4. Other

13 COPD Cochrane Review studies n = >13,000 ICS - reduces exac (<50% pred) - improves QOL (marginal) - +/- on FEV1.0 decline - no effect mortality

14 TORCH Feb 2007 Death Pneumonia Exac/year Placebo 15.2% 12% 1.13 Combination 12.6% 19% 0.85 p=0.052 p=<0.05 p=<0.05

15 ICS and Pneumonia (Samy Suissa) Thorax Oct 2013 n=163,000 COPD > 55 yrs - 20,000 adm CAP nested case controls Overall, HR = FP = Dose responsive - Beclo = Cessation = drop risk - Bud = 1.2 NNH = (* note NNT exac = 14-44)

16 WISDOM showed no significant difference in mod/sev COPD exacerbations for ICS withdrawal group BUT a 38 ml greater reduction in trough FEV 1 than the ICS continuation group at 18 weeks Tricco AC et al. BMJ Open 2015;5:e009183

17 COPD - Pred Change FEV1.0 % sput eos

18 COPD - Eos n = 243 <2% eos >2% eos 20% fail 20% fail Pred 11% fail No Pred 66% fail

19 COPD exac n=3255 LABA (Vil) LABA + ICS (FF) >6 Blood Eos %

20 EOS Reactive Non-smoker Atopy COPD Step 3 EOS Fixed Recurrent exac/infection Add ICS LABA/LAMA +/- Antibiotics Step 4

21 vol 100/yr 30/yr 30/yr 25 age

22 COPD - ECLIPSE 38% - >40 ml/yr decline 31% ml/yr decline 23% decline/improve 8% - >21 - improve

23 COPD Exac Cat Chang - Waikato N = 248 COPD exac prospective cohort Day 30 mort 8.8% (17% Trop) (28% BNP) Day 365 mort 17.7% (ECLIPSE = 35 50% mortality 1 year post exac)

24 4 yr mortality (%) COPD ECLIPSE - Lung attack * >NSTEMI # exac in past year -?Aspirin

25 COPD ECLIPSE - Lung attack 6 months to return SGRQ to normal 2-3 mls drop per attack

26 So ICS when.? A. Poor lung function ( < 50% ) B. 2 or more exac. C. Eosinophils???

27 COPD Mar 1, 2016 LAMA - Tiotropium - Respimat - Handihaler - Umeclindinium - Glycopyrronium LAMA/LABA - Tio/olodaterol - Umeclind/Vilanterol - Glyco/Indacaterol ICS/LABA - Bud/Formot - Flu/Salm - Flu/Vilanterol

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29 Network meta-analysis plots. (A) Exacerbation

30 Results 112 abstract citations found 97 studies excluded ( not relevant ) = 15 full studies reviewed Further 5 excluded for wrong design, study design, duplicate study or review article + 10 studies from unpublished and manufacturers Total= 20 reports( 23 studies ) = 27,172 pts (19 double blinded )

31 Exacerbations 16 trials = mod; 19 trials =severe For Moderate exacerbations only: Comb> placebo HR=0.66 Comb> LABA HR=0.82 Comb =LAMA HR 0.92 ( ) No differences for severe exac

32 Plan 1. SABD 2. LAMA mono 3. a) If SOB LAMA/LABA b) If exac/severe Triple 4. +/- Antibiotics HR 0.93

33 GOLD 2011 subtypes CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease; mmrc, modified Medical Research Council questionnaire. GOLD, Global strategy for the diagnosis, management and prevention of COPD, Available at: (accessed February 2013).

34 Are RCT patients the same as real-life patients with obstructive lung disease? Asthma patients eligible for RCT COPD patients eligible for RCT COPD, chronic obstructive pulmonary disease; FEV 1, forced expiratory volume in 1 second; ICS inhaled corticosteroid; RCT, randomised controlled trial; S, smoker; XS, ex-smoker; VAS, visual analogue scale. Herland K et al. Respir Med 2005; 99: 11 9.

35 COPD - GP 1. Clear recognition / diagnosis 2. Smoking Cessation 3. Antibiotics / steroids prn scripts 4. Acute appointment times CURB 65 / VBG 5. Vaccination

36 Plan 1. SABD 2. LAMA mono 3. a) If SOB LAMA/LABA b) If exacerbation/severe Triple 4. +/- Antibiotics HR 0.93