Prescribing guidelines: Management of COPD in Primary Care

Transcription

1 Prescribing guidelines: Management of COPD in Primary Care Establish diagnosis of COPD in patients 35 years with appropriate symptoms with history, examination and spirometry (FEV1/FVC ratio < 70%) Establish severity of disease by FEV 1 as % predicted Management of RISK FACTORS plus EDUCATION plus IMMUNISATION Smoking cessation, Lifestyle intervention, Diet/Exercise, Influenza vaccine (annual), Pneumococcal vaccine, Psychological issues. Pulmonary rehabilitation if functionally disabled- Consider referral to pulmonary rehabilitation if MRC score 3 Abbreviations: SABA- Short acting β 2 agonist SAMA- Short acting muscarinic antagonist LABA- Long acting β agonist LAMA- Long acting muscarinic agent ICS- Inhaled corticosteroid PRN- when required STEP 1 Breathlessness and / Exercise limitation Start SABA Assess response in 4 weeks and review before proceeding to next option If no benefit or persistent symptoms consider adding SAMA Salbutamol - Two puffs when required Terbutaline - one puff when required MDI via volumatic spacer SAMA This should only be considered if there is intolerance to SABA Intolerance refers to an inability to tolerate the adverse effects of a medication, generally at therapeutic or subtherapeutic doses Ipratropium CFC-free aerosol Two puffs four times daily STEP 2 Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from: SYMPTOMATIC RELIEF OF PERSISTENT BREATHLESSNESS IN MODERATE TO VERY SEVERE COPD (FEV1 < 80%) REDUCING EXACERBATIONS IN MODERATE TO VERY SEVERE COPD (FEV1 < 80%) With persistent breathlessness Consider adding either LABA(OPTION 1) or LAMA (OPTION 2) With 2 exacerbations in last 12months Start: ICS + LABA Option 1. Add LABA Continue SABA Assess response in 4weeks and review. 1. If there is optimal benefits on LABA continue and no need to add other regimen 2. If no benefit - Discontinue the use of LABA and consider option 2(LAMA) 3. If there is some benefit on LABA but not full symptomatic improvement, consider adding a LAMA to LABA Option 2. Add LAMA Continue SABA (Stop SAMA) Assess response in 4weeks and review. 1. If there is optimal benefits on LAMA continue and no need to add other regimen 2. If no benefit - Discontinue the use of LAMA and consider option 1(LABA) 3. If there is some benefit on LAMA but not full symptomatic improvement, consider adding a LABA (Consider LABA+ LAMA if ICS declined or not tolerated) Clinicians are reminded that black triangle drugs ( ) are relatively new and intensively monitored. Report adverse reactions and suspected reactions via the Yellow Card Scheme by healthcare professionals and members of the public Use of ICS in COPD should be in combination with a LABA Remember to stop single device LABA in patient starting on ICS+LABA combination Clinicians are reminded that black triangle drugs ( ) are relatively new and intensively monitored. Report adverse reactions and suspected reactions via the Yellow Card Scheme by healthcare professionals and members of the public LABA LAMA ICS+LABA combination Formoterol *Easyhaler Formoterol 12micrograms twice daily (maximum per dose 24micrograms); for symptom relief additional doses may be taken to maximum daily dose; maximum 48microgram per day Tiotropium handihaler Breath actuated dry capsule; use one capsule in handihaler once daily Different brands available; consider using brand recommended on script switch Beclometasone with Formoterol 100/6microgram Fostair MDI 100/6mcg via volumatic spacer Two inhalation twice a day Fostair Nexthaler 100/6 Two inhalation twice a day Fluticasone furoate/vilanterol (Relvar Ellipta) 92/22mcg One puff daily Salmeterol Available as CFC-free aerosol 25micrograms per actuation; Two puffs twice a day. *Inhalation of powder 50microgram per dose; One blister twice a day Different brands available; prescribe by a brand name. Consider using brand recommended on script switch Umeclidium (Incruse Ellipta ) Consider in new patients By inhalation of powder, each 65microgram of umeclidium bromide deliver 55microgram of umeclidium One inhalation dose once daily Budesonide with Formoterol DuoResp spiromax 160/4.5 DuoResp spiromax 320/9 Symbicort 200/6 turbohaler/mdi Symbicort 400/12 turbohaler Two puffs twice daily One puff twice daily Two puffs twice daily One puff twice daily 1

2 In patients requiring both LABA and LAMA, once response is satisfactory: May consider the option of a LABA+LAMA combination in a single device If exacerbation persists, consider Triple therapy with LABA/ICS plus LAMA plus PRN SABA (stop SAMA) If patient is on a combination inhaler for LABA+ LAMA., stop this. Start on LAMA and add an ICS+LABA combination Remember use of ICS in COPD should be in combination with a LABA Umeclidium /Vilanterol ( Anoro Ellipta ) 55/22microgram One puff daily Aclidinium/Formoterol ( Duaklir Genuair )12/340 micrograms One puff twice a day Fostair / Incruse Ellipta Relvar / Incruse Ellipta Fostair / Tiotropium ENSURE ALL INHALERS ARE PRESCRIBED BY BRAND NAMES If still symptomatic refer to specialist SAMA Short Acting β 2 Agonists SAMA- Short acting muscarinic antagonists Salbutamol Terbutaline Ipratropium LABA: Long Acting β 2 agonists LAMA: Long Acting Muscarinic Antagonist LABA+LAMA Combination Tiotropium (Braltus zonda ) Incruse Ellipta Salmeterol(Soltel ) Formoterol Easyhaler Anoro Ellipta Duaklir Genuair Inhaled Corticosteroids (ICS) in a combination inhaler (I CS+ LABA) Fostair Relvar Ellipta 92/22 DuoResp Symbicort 2

3 Value pyramid for COPD (The London Respiratory Team 2013) QALY= quality-adjusted life year It is considered that interventions costing the NHS less than 20,000 per QALY gained is cost effective while cost between 20,000 and 30,000 per QALY gained may also be deemed cost effective. Triple therapy in COPD (i.e. an ICS plus LAMA plus LABA) cost between 7,000 and 187,000 (upper limit) which is well above NICE threshold of 21,000 per QALY for a treatment to be regarded as cost effective. This highlight the importance for Non-drug interventions and lifestyle advise such as stopping smoking, flu vaccination and pulmonary rehabilitation as these interventions are more cost effective than COPD drug treatments. 3

4 Assess each new treatment step four weeks after initiation Check inhaler technique Consider alternative diagnosis Has the treatment made a difference to you? Is your breathing easier in any way? Can you do somethings that you could do before or do the same things faster? Are you less breathless than before when doing these things? Record MRC scale Referral to Specialist Community Service( Louise House ) /a specialist When there is : Diagnosis uncertainty Uncontrolled COPD Onset of cor pulmonale Assessment of surgery: bullous lung disease, lung reduction surgery Rapid decline in FEV 1 Age <40 or FH of alpha 1 antitrypsin deficiency Frequent infection If no benefit STOP treatment and consider alternative. Try to prescribe the same type of device for each type of drug Nebulisers Pulmonary Rehabilitation: Consider referral to pulmonary rehabilitation if MRC score is 3 Regular nebulisers are rarely recommended and should only be initiated following consultant advice Consider high dose bronchodilator via a large volume spacer Lifestyle advice: Smoking cessation- promote at every opportunity Dietary advice- if BMI < 20 OR >30 Exercise- promote gentle exercise Self-Management Consider written self -management plan for all patients. Consider rescue pack for appropriate patients. Prescribe antibiotics in line with antimicrobial guidance Immunisation: Influenza annually Pneumococcal as per green book Anxiety and Depression: Screen for anxiety and depression using the PHQ-9 / HADS score Oxygen therapy: If SPO 2 <92% ( at rest and stable) refer to Home Oxygen Service and Review(HOSAR) Respiratory and COPD Services, Louise House Shrewsbury Tel contact: Chronic Productive Cough: Consider trial of carbocisteine. If capsules are not tolerated consider using 750mg/sachet rather than liquid syrup (One sachet TDS then reduce to One sachet BD). This should be stopped if there is no benefit after a 4-week trial. 4

5 HOW TO USE A VOLUMATIC SPACER DEVICE Single Breath Technique 1. Remove the cap. 2. Shake the inhaler and insert into the device. 3. Place the mouthpiece in the mouth. 4. Press (activate) the canister once to release a dose of the drug. 5. Take a deep, slow breath in. 6. Hold the breath for about 10 seconds, then breathe out through the mouthpiece. 7. Remove the device from the mouth. For a further dose wait a few seconds before shaking the spacer and MDI together 2 or 3times. Then repeat steps 3-7. ALWAYS DEMONSTRATE TO THE PATIENT HOW TO USE THE SPACER DEVICE. HOW TO USE A VOLUMATIC SPACER DEVICE Multiple Breath Technique 1. Remove the cap. 2. Shake the inhaler and insert into the device. 3. Place the mouthpiece in the mouth. 4. Make sure the mouthpiece valve can be activated by breathing in and out slowly and gently. (The device will make a clicking sound as the valve opens and closes). 5. Press (activate) the canister once and breathe in and out 5 or 6 times (tidal breathing). 6. Remove the device from the mouth. For a further dose wait a few seconds before shaking the spacer and MDI together 2 or 3times. Then repeat steps 5-6. ALWAYS DEMONSTRATE TO THE PATIENT HOW TO USE THE SPACER DEVICE. 5