Confronting the Challenges of COPD. What is New in The Approaches to Diagnosis, Treatment, and Patient Outcomes

Transcription

1 Confronting the Challenges of COPD What is New in The Approaches to Diagnosis, Treatment, and Patient Outcomes

2 COPD Definition GOLD: Global Initiative for Chronic Obstructive Lung Disease Common, preventable, treatable partially reversible Characterized by persistent airflow limitation; usually progressive and disabling; associated with chronic inflammatory response in airways/lung to noxious particles or gases Chronic bronchitis Emphysema Exacerbations and comorbidities contribute to overall severity Global Initiative for Chronic Obstructive Lung Disease (GOLD) Accessed September 24,

3 Burden of COPD in the United States Total costs from hospitalization and absenteeism estimated at $36 billion COPD exacerbations account for >70% of total costs 13 million office visits/year due to exacerbations Disproportionately affects individuals of lower socioeconomic status Reprinted from The Lancet Respiratory Medicine, 4(6), Han MK et al, Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective, , Copyright 2016, with permission from Elsevier. Han MK et al. Lancet Respir Med. 2016;4(6): ; Ford ES et al. Chest. 2013;144(1): ; Ford ES et al. Chest. 2013;143(5): ; Han MK et al. Lancet Respir Med. 2016;4(6):

4 COPD Is Underdiagnosed Roughly half of those in the United States with COPD are undiagnosed ~15 million Americans Reprinted from The Lancet Respiratory Medicine, 4(6), Han MK et al, Meeting the challenge of COPD care delivery in the USA: a multiprovider perspective, , Copyright 2016, with permission from Elsevier. Han MK et al. Lancet Respir Med. 2016;4(6): ; Haroon S et al. Int J Chron Obstruct Pulmon Dis. 2015;10:

5 Screening for Chronic Obstructive Pulmonary Disease US Preventive Services Task Force Recommendation Statement Similar to 2008, the USPSTF did not find evidence that screening for COPD in asymptomatic persons improves health-related quality of life, morbidity, or mortality. The USPSTF determined that early detection of COPD, before the development of symptoms, does not alter the course of the disease or improve patient outcomes. The USPSTF concludes with moderate certainty that screening for COPD in asymptomatic persons has no net benefit. US Preventive Services Task Force (USPSTF), Siu AL et al. JAMA. 2016;315(13):

6 Screening vs Case Finding Many individuals at increased risk for COPD self-restrict activity to minimize symptoms USPSTF recommendation is based on lack of evidence, not negative evidence GOLD recommends case-finding in symptomatic patients, but does not recommend screening in asymptomatic populations Future trials are needed to better assess the effects of screening and treatment of at-risk individuals in primary care on long-term health outcomes US Preventive Services Task Force (USPSTF), Siu AL et al. JAMA. 2016;315(13):

7 Case Finding: A New Approach Joint partnership between NHLBI and COPD Foundation 5-item questionnaire plus Peak Expiratory Flow Designed to identify individuals who are symptomatic or have history of exacerbations In a case-control study, CAPTURE exhibited a sensitivity of 95.7% and a specificity of 67.8% for differentiating cases from no-copd control subjects NHLBI=National Heart, Lung, and Blood Institute. Martinez FD, Kraft M. Am J Respir Crit Care Med. 2017;195(9):

8 Diagnosis *Postbronchodilator FEV 1 /FVC measured 10 to 15 minutes after 2 to 4 puffs of a short-acting bronchodilator FEV 1= forced expired volume in 1 second; FVC=forced vital capacity. Global Initiative for Chronic Obstructive Lung Disease (GOLD) Accessed March 10,

9 Spirometry Required for Diagnosis Uses of spirometry in COPD include: Confirm an FEV1/FVC ratio <0.7 after bronchodilator Assess disease severity Differentiate COPD from other diseases Monitor disease progression Assess response to therapy Spirometry for Health Care Providers. Global Initiative for Chronic Obstructive Pulmonary Disease. Accessed September 24,

10 Case Finding: A New Approach Joint partnership between NHLBI and COPD Foundation 5-item questionnaire plus Peak Expiratory Flow Designed to identify individuals who are symptomatic or have history of exacerbations In a case-control study, CAPTURE exhibited a sensitivity of 95.7% and a specificity of 67.8% for differentiating cases from no-copd control subjects NHLBI=National Heart, Lung, and Blood Institute. Martinez FD, Kraft M. Am J Respir Crit Care Med. 2017;195(9):

11 GOLD Grading System: FEV1 Airflow Limitation Very severe FEV 1 <30% predicted GOLD Grade 4 GOLD Grade 1 Mild FEV 1 80% predicted Severe 30% FEV 1 <50% predicted GOLD Grade 3 GOLD Grade 2 Moderate 50% FEV 1 <80% predicted Postbronchodilator FEV 1 /FVC <.70 Confirms presence of persistent airflow limitation Supports diagnosis of COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD), Accessed September 24,

12 GOLD Combined Assessment: Symptoms/Exacerbation Risk C D >2 A B 1 0 Risk (Exacerbation history) mmrc 0-1 CAT <10 Symptoms (mmrc or CAT score) mmrc 2 CAT 10 CAT=COPD Assessment Test; mmrc=modified Medical Research Council. Used with permission from the Global Strategy for Diagnosis, Management and Prevention of COPD 2014, Global Initiative for Chronic Obstructive Lung Disease (GOLD), Accessed 5/1/17 12

13 Goals for Treatment of Stable COPD Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24,

14 Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report GOLD Executive Summary Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24, 2017.; Vogelmeier CF et al. Am J Respir Crit Care Med. 2017;195(5):

15 A Modification of Therapeutic Recommendations Group C Further Exacerbation(s) LAMA + LABA LAMA LABA + ICS Group D Consider roflumilast if FEV 1 < 50% pred and patient has chronic bronchitis Further Exacerbation(s) Further Exacerbation(s) LAMA LAMA + LABA + ICS LAMA + LABA Consider macrolide Persistent Symptoms/Further Exacerbations LABA + ICS Group A Continue, stop, or try alternative class of bronchodilator Group B LAMA + LABA Evaluate effect A bronchodilator Persistent symptoms A long-acting bronchodilator (LABA or LAMA) Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24,

16 Symptomatic Response to Dual Bronchodilators Is Dependent On Baseline Symptom Burden Reprinted from Chest, Martinez FJ et al, Baseline symptom score impact on benefits of glycopyrrolate/formote rol metered dose inhaler in COPD, /j.chest [Epub ahead of print], Copyright 2017, with permission from Elsevier. *Least squared mean difference (95% CI) in change in baseline in SGRQ at Week 24. Pooled data from PINNACLE-1 and PINNACLE-2. The primary end point was change from baseline in morning pre-dose trough FEV 1. FF=formoterol fumarate; GFF=glycopyrrolate/formoterol fumarate; GP=glycopyrrolate; LSM=least squares mean; MCID=minimum clinically important difference; MDI=metered-dose inhaler; SGRQ=St George Respiratory Questionnaire; T=tiotropium. Martinez FJ et al. Chest Jul /j.chest [Epub ahead of print]. 16

17 A Modification of Therapeutic Recommendations Group C Further Exacerbation(s) LAMA + LABA LAMA LABA + ICS Group D Consider roflumilast if FEV 1 < 50% pred and patient has chronic bronchitis Further Exacerbation(s) Further Exacerbation(s) LAMA LAMA + LABA + ICS LAMA + LABA Consider macrolide Persistent Symptoms/Further Exacerbations LABA + ICS Group A Continue, stop, or try alternative class of bronchodilator Group B LAMA + LABA Evaluate effect A bronchodilator Persistent symptoms A long-acting bronchodilator (LABA or LAMA) Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24,

18 LAMA Reduces Exacerbations Compared With a LABA Reprinted from The Lancet Respiratory Medicine, 1(7), Decramer ML et al; INVIGORATE investigators, Once-daily indacaterol versus tiotropium for patients with severe chronic obstructive pulmonary disease (INVIGORATE): a randomised, blinded, parallel-group study, , Copyright 2013, with permission from Elsevier. Adapted from Vogelmeier C et al; POET-COPD Investigators. N Engl J Med. 2011;364(12): ; Decramer ML et al; INVIGORATE Investigators. Lancet Respir Med. 2013;1(7):

19 A Modification of Therapeutic Recommendations Group C Further Exacerbation(s) LAMA + LABA LAMA LABA + ICS Group D Consider roflumilast if FEV 1 < 50% pred and patient has chronic bronchitis Further Exacerbation(s) Further Exacerbation(s) LAMA LAMA + LABA + ICS LAMA + LABA Consider macrolide Persistent Symptoms/Further Exacerbations LABA + ICS Group A Continue, stop, or try alternative class of bronchodilator Group B LAMA + LABA Evaluate effect A bronchodilator Persistent symptoms A long-acting bronchodilator (LABA or LAMA) Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24,

20 LABA/LAMA vs ICS/LABA for Exacerbations From The New England Journal of Medicine, Wedzicha JA et al; FLAME Investigators, Indacaterol glycopyrronium versus salmeterol fluticasone for COPD, 374, Copyright 2016 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society. Wedzicha JA et al; FLAME Investigators. N Engl J Med. 2016;374(23):

21 ICS/LABA Decreased Exacerbations Compared With Usual Care From The New England Journal of Medicine, Vestbo J et al; Salford Lung Study Investigators, Effectiveness of fluticasone furoate vilanterol for COPD in clinical practice, 375, Copyright 2016 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society. Vestbo J et al; Salford Lung Study Investigators. N Engl J Med. 2016;375(13):

22 Rate of Decline in FEV 1 is Tempered by ICS Calverley PMA, et al. AJRCCM 2017 as doi: /rccm OC 22

23 FF/VI Showed the Greatest Benefit Over VI in Exacerbation Prevention in Patients With 2% Blood Eosinophils(Post Hoc Analysis) Reprinted from The Lancet Respiratory Medicine, 3(6), Pascoe S et al, Blood eosinophil counts, exacerbations, and response to the addition of inhaled fluticasone furoate to vilanterol in patients with chronic obstructive pulmonary disease: a secondary analysis of data from two parallel randomised controlled trials, , Copyright 2015, with permission from Elsevier. Pascoe S et al. Lancet Respir Med. 2015;3(6):

24 Moderate to Severe Exacerbations (annualized rate) IND/GLY Reduced the Rate of Moderate or Severe Exacerbations vs SFC Over 52 Weeks in Patients With <2 and 2% Blood Eosinophils at Randomization (pre-specified analysis) RR (95% CI) 0.80 (0.68, 0.93), P=.004 RR (95% CI) 0.85 (0.75, 0.96), P=.010 SFC 50/500 µg bid IND/GLY 110/50 µg qd <2 Percentage blood eosinophils (%) 2 IND/GLY=indacaterol-glycopyrronium; RR=rate ratio; SFC=salmeterol-fluticasone. Wedzicha JA et al; FLAME Investigators. N Engl J Med. 2016;374(23):

25 A Modification of Therapeutic Recommendations Group C Further Exacerbation(s) LAMA + LABA LAMA LABA + ICS Group D Consider roflumilast if FEV 1 < 50% pred and patient has chronic bronchitis Further Exacerbation(s) Further Exacerbation(s) LAMA LAMA + LABA + ICS LAMA + LABA Consider macrolide Persistent Symptoms/Further Exacerbations LABA + ICS Group A Continue, stop, or try alternative class of bronchodilator Group B LAMA + LABA Evaluate effect A bronchodilator Persistent symptoms A long-acting bronchodilator (LABA or LAMA) Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24,

26 A Modification of Therapeutic Recommendations Group D Consider roflumilast if FEV 1 < 50% pred and patient has chronic bronchitis Consider macrolide Further Exacerbation(s) Further Exacerbation(s) LAMA + LABA + ICS Persistent Symptoms/Further Exacerbations LAMA LAMA + LABA LABA + ICS Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24,

27 Triple Therapy for Exacerbations Additional effect of a LAMA added to an ICS/LABA BDP=beclomethasone dipropionate; GB=glycopyrronium bromide. Adapted from Singh D et al. Lancet. 2016;388(10048):

28 FULFIL Trial: Once-Daily Triple Therapy for Patients with Chronic Obstructive Pulmonary Disease FEV 1 E-RS Reprinted with permission of the American Thoracic Society. Copyright 2017 American Thoracic Society. Lipson DA et al FULFIL Trial: Once-daily triple therapy for patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 196, The American Journal of Respiratory and Critical Care Medicine is an official journal of the American Thoracic Society. BUD/FOR=budesonide/formoterol; E-RS=EXACT-Respiratory Symptoms; LS=least squares; UMEC=umeclidinium. Lipson DA et al. Am J Respir Crit Care Med. 2017;196(4):

29 A Modification of Therapeutic Recommendations Group D Consider roflumilast if FEV 1 < 50% pred and patient has chronic bronchitis Consider macrolide Further Exacerbation(s) Further Exacerbation(s) LAMA + LABA + ICS Persistent Symptoms/Further Exacerbations LAMA LAMA + LABA LABA + ICS Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24,

30 Azithromycin Effect Noted Across a Wide Variety of Patients Reprinted with permission of the American Thoracic Society. Copyright 2017 American Thoracic Society. Han MK et al Predictors of chronic obstructive pulmonary disease exacerbation reduction in response to daily azithromycin therapy. Am J Respir Crit Care Med, 189, The American Journal of Respiratory and Critical Care Medicine is an official journal of the American Thoracic Society. Han MK et al. Am J Respir Crit Care Med. 2014;189(12):

31 Mean Rate of COPD Severe Exacerbations per Patient per Year Roflumilast Response Is Particularly Evident in COPD Patients With Prior Hospitalizations RR=0.65 (95% CI 0.48, 0.89), 0.7 P< % reduction ROF (n=322) Placebo (n=319) RR=0.92 (95% CI 0.67, 1.28), ns 7.6% reduction ROF (n=647) Placebo (n=647) Rate of moderate and severe exacerbations Number of severe exacerbations/ hospitalizations in 12 months prior to randomization ROF 0 Number of participants at risk Roflumilast (n=1178) Placebo 0 Placebo (n=1174) ROF 1 Rate ratio (95% Cl) P value (0.8, 1.18) (0.60,0.93) 25% reduction The primary endpoint was the annual rate of moderate (requiring treatment with SCS and/or antibiotics) and severe (necessitating hospitalization or leading to death) exacerbations ROF=roflumilast 500 μg qd. Placebo Adapted from Rabe KF et al. Eur Respir J Jul 5;50(1). doi: / ; Adapted from Martinez FJ et al. Am J Resp Crit Car Med. 2016;194(5):

32 A Modification of Therapeutic Recommendations Step Down Is Possible Structure for Follow-up Is Suggested Group D Consider roflumilast if FEV 1 < 50% pred and patient has chronic bronchitis Further Exacerbation(s) Consider macrolide Further Exacerbation(s) LAMA + LABA + ICS Persistent Symptoms/Further Exacerbations LAMA LAMA + LABA LABA + ICS Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24,

33 ICS Can Be Withdrawn Withdrawal of Inhaled Glucocorticoids From The New England Journal of Medicine, Magnussen H et al; WISDOM Investigators, Withdrawal of inhaled glucocorticoids and exacerbations of COPD, 371, Copyright 2014 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society. IGC=inhaled glucocorticoids. Magnussen H et al. N Engl J Med. 2014;371(14):

34 ICS Can Be Withdrawn Withdrawal of Inhaled Glucocorticoids From The New England Journal of Medicine, Magnussen H et al; WISDOM Investigators, Withdrawal of inhaled glucocorticoids and exacerbations of COPD, 371, Copyright 2014 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society. IGC=inhaled glucocorticoids. Magnussen H et al. N Engl J Med. 2014;371(14):

35 WISDOM Study: Stepwise Withdrawal of ICS in COPD: Role of Eosinophils at Baseline Factors Number of Patients Rate Ratio P value Adapted from Watz H et al. Lancet Respir Med. 2016;4(5):

36 A Modification of Therapeutic Recommendations Step Down Is Possible Structure for Follow-up Is Suggested Group D Consider roflumilast if FEV 1 < 50% pred and patient has chronic bronchitis Consider macrolide Further Exacerbation(s) Further Exacerbation(s) LAMA + LABA + ICS Persistent Symptoms/Further Exacerbations LAMA LAMA + LABA LABA + ICS Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24,

37 ISSUES OF INHALER DEVICES 37

38 Issues of Inhaler DEVICES No single inhaler will satisfy the needs of all patients 28% to 68% of patients do not use inhalers correctly A sub-optimal technique can result in decreased lung delivery and potentially reduced efficacy The proliferation of inhalation devices in the market can result in confusion for clinicians, nurses, respiratory therapists, and patients Each available device requires specific inhalation techniques Studies have demonstrated lack of knowledge in the use of devices by health care professionals 39% to 67% of HCPs are unable to adequately perform or describe inhalation techniques Physicians need to select the right inhaler for each patient Knowing each product s characteristics is key Baverstock et al. Thorax, 2010;65:A117-A118; Labiris NR, Dolovich MB. Br J Clin Pharmacol. 2003;56(6): ; Lewis RM, Fink JB. Resp Care Clin N Am. 2001;7(2): , vi. 38

39 Factors That Determine Selection of an Inhaler Delivery System Clinician Factors Deliver wide range of therapies Clinical efficacy/safety Type of prescribed medications (ICS vs bronchodilator) Patient s disease severity/inspiratory flow Ease of use/liked by patients Cost/Reimbursement insurance coverage Patient Factors Lifestyle/Preference Disease severity Cost/Reimbursement Clinical setting/caregiver Physical ability/dexterity Cognitive ability Dolovich MB et al; American College of Chest Physicians; American College of Asthma, Allergy, and Immunology. Chest. 2005;127(1): ; Chapman KR, et al. Eur Respir Rev. 2005;14: ; Vincken W et al; ADMIT Group. Prim Care Respir J. 2010;19(1):10-20; Rau JL. Respir Care. 2006;51(2) Barrons R et al. Am J Health Syst Pharm. 2011;68(13):

40 The Use of Inhaled Delivery Devices Age is a major factor that determines correct use of inhaler devices secondary to decreased muscle strength, memory problems, and loss of coordination 40

41 Mishandling of Inhaler Devices in a Primary Care Setting Frequency of Critical Errors by Device According to Age Class n = 3811 Molimard M et al. J Aerosol Med. 2003;16(3): Reprinted with permission Molimard M et al. J Aerosol Med. 2003;16(3):

42 PIF (L/min) Flow-Independent Delivery System Required for Elderly Patients With Severe COPD Peak Inspiratory Flow (PIF) According to Age and Disease Severity Age (years) Mild COPD Moderate COPD Severe COPD R=0.84 (P<.0001) Turbohaler Accuhaler, Diskus Jarvis S et al. Age Ageing. 2007;36(2): Jarvis S et al. Inhaled therapy in elderly COPD patients; time for re-evaluation? Age and Aging, 2007, 36(2), , by permission of Oxford University Press. 42

43 The Non-Compliance Spiral Use Of Inhaler Devices Lack of compliance Patients misuse of inhalers Health Care Costs Waste of inhalers Worsening of symptoms Health Care Provider step-up treatments Mortality Hospitalizations Morbidity Adapted from Batterink J. Can J Hosp Pharm. 2012;65(2):

44 Key Points on Inhalation Devices Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24,

45 What the Pulmonary Specialist Should Know About the New Inhalation Therapies Know the types of devices that are available to deliver specific drugs and classes of drugs Appreciate the advantages and disadvantages of each device Choose devices that the patient can and will use effectively Choose devices that have been approved by the appropriate authorities Train patients about the correct inhalation maneuver that is appropriate for the device being prescribed Check the patient s inhaler technique regularly Review the patient s adherence to treatment at each visit Not switch to a new device without the patient s involvement and without follow-up education on how to use the device properly Laube BL et al; European Respiratory Society; International Society for Aerosols in Medicine. Eur Respir J. 2011;37(6):

46 Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24,

47 Pulmonary Rehabilitation: Science Reprinted with permission from Pulmonary Rehabilitation in the Treatment of Chronic Obstructive Pulmonary Disease, September 15, 2010, Vol 82, No 6, American Family Physician Copyright 2010 American Academy of Family Physicians. All Rights Reserved AACVPR=American Association of Cardiovascular and Pulmonary Rehabilitation; ACCP=American College of Chest Physicians; ACP=American College of Physicians; Nici L et al. Am Fam Physician. 2010;82(6):

48 Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24,

49 From The New England Journal of Medicine, Long-Term Oxygen Treatment Trial Research Group, Albert RK et al, A randomized trial of long-term oxygen for COPD with moderate desaturation, 375, Copyright 2016 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society. LTOT=long-term oxygen treatment. Long-Term Oxygen Treatment Trial Research Group, Albert RK et al. N Engl J Med. 2016;375(17):

50 LTOT=long-term oxygen treatment. Long-Term Oxygen Treatment Trial Research Group, Albert RK et al. N Engl J Med. 2016;375(17):

51 Intervention Bronchoscopy and Surgery BODE=B, body mass index; O, airway obstruction; D, dyspnea; E, exercise tolerance. Initiative for Chronic Obstructive Lung Disease (GOLD) 2017, reprinted with permission. Accessed September 24,

52 Adherence to COPD Medications Is Poor More than half of patients with COPD will stop new prescriptions after the first month Sustained adherence continues to decay over time Persistence with any inhaler was 36%, 23%, and 17% at years 1, 2, and 3, respectively Bender BG et al. J Allergy Clin Immunol. 2006;118(4): ; ecere LM et al. COPD. 2012;9(3): ; Penning-van Beest F et al. Respir Med. 2011;105(2): Reprinted from Respiratory Medicine, 105(2), Penningvan Beest F et al, Three-year dispensing patterns with long-acting inhaled drugs in COPD: a database analysis, , Copyright 2011, with permission from Elsevier. 52

53 Multiple Factors Affect Adherence to Therapy Horne R. Chest. 2006;130(1 suppl):65s-72s. Reprinted from Chest, 130(1 suppl), Horne R, Compliance, adherence, and concordance: implications for asthma treatment, 65S-72S, Copyright 2006, with permission from Elsevier. 53

54 Recent Studies Support Several Strategies to Improve Adherence Use of individualized action plans Simplify treatment regimen Plans that are clinically effective and user-friendly Fewer doses per day Oral vs inhaled medications Vehicles that deliver 2 drugs at once Use of home visits by health care staff to reinforce adherence Use of self-monitoring, goal-setting, and other self-management techniques 54

55 Patient Education: Key Educational Messages for COPD Basic facts about COPD Contrast normal and COPD airways Roles of medications and potential adverse events Long-term maintenance and quick-relief medications Relevant environmental triggers and reducing exposures Building an action plan: when and how to take rescue actions Skills Inhalers, nebulizers, spacers, symptoms, and early warning signs 55

56 COPD Self-Management Characteristics of successful programs Self-management intervention, including an action plan in the event of an exacerbation Case manager coordination Patient education Periodic communication (monthly visits or phone calls) Unsuccessful programs failed to intervene when symptoms worsened Management did not vary within continuum of disease Bourbeau J, Saad N. Chron Respir Dis. 2013;10(2):99-105; Bucknall CE et al. BMJ. 2012;344:e1060; Fan VS et al. Ann Intern Med. 2012;156(10):

57 Monitoring and Follow-up In order to adjust therapy appropriately as the disease progresses, each follow-up visit should include a discussion of the current therapeutic regimen. Monitoring should focus on: Dosages of prescribed medications Adherence to the regimen Inhaler technique Effectiveness of the current regime Side effects Treatment modifications should be recommended. Global Initiative for Chronic Obstructive Lung Disease (GOLD) Accessed September 24,

58 Summary: Strategies to Ensure Adherence 58

59 FINAL THOUGHTS 59

60 THANK YOU! 60