News on Evidence-Based Care Fourth Quarter 2013 Volume 5 Issue 4

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1 SPECIAL EDITION: COPD CME AVAILABLE! News on Evidence-Based Care Fourth Quarter 2013 Volume 5 Issue 4 Update on Chronic Obstructive Lung Disease (COPD) 2013 During 2013, the Institute for Evidence-Based Care reinstated the COPD evidence review team to review current best practices in the field. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) updated their guidelines and provided some new and helpful material for clinicians. The complete document can be accessed at The COPD Evidence Review Team included: Josh Havard, RRT; Michelle Kohute, Pharm D; John Perrotta, RRT; Adrian Pristas, M.D.; Joseph Reichman, M.D.; Kathleen Russell-Babin, Ph.D., R.N.; and Jean Stoerger, Pharm D. Many thanks go out to this team for their commitment to this work. The 2013 Guidelines Perhaps the biggest change in the guidelines was a de-emphasis on the stages of COPD and an emphasis on a combination model of risk assessment. The guidelines shared a model for assessing the risk of exacerbation using the mmrc and spirometric classification of Low (categories 1 and 2) or high (categories 3 and 4) risk combined with exacerbation history to portray the full degree of risk of exacerbation. The following slides come from the GOLD teaching slide set, used with permission to educate Meridian providers. The mmrc (Modified Medical Research Council Dyspnea Scale) is composed of five levels. This tool measures the impact of breathlessness. Mahler and Wells found the tool to be reliable. Mahler DA, Wells CK. Evaluation of clinical methods for rating dyspnea. Chest 1988;93: Grade 0 I only get breathless with strenuous exercise 1 I get short of breath when hurrying on the level or walking up a slight hill 2 I walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level 3 I stop for breath after walking about 100 yards or after a few minutes on the level 4 I am too breathless to leave the house or I am breathless when dressing Alternately, the CAT may be used. The CAT (COPD Assessment Tool) is a copyrighted tool from Glaxo-Smith-Klein. It can be accessed at In eight questions, the patient rates the impact of COPD on their health status. Total scores range from Higher scores represent a stronger impact on the disease on a patient s life. Acceptable reliability and validity have been demonstrated for this tool.

2 The 2013 Guidelines For the combined assessment, start with assessing symptoms first. Two exacerbations or more within the last year or an FEV1 < 50 % of predicted value are indicators of high risk. Use the combination model to assess this.

3 The 2013 Guidelines GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE (GOLD): TEACHING SLIDE SET January 2013; used with permission.

4 The 2013 Guidelines With this in mind, the guidelines moved away from treatment by stage to treatment by combined assessment, as seen on the following slides:

5 The 2013 Guidelines

6 The 2013 Guidelines GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE (GOLD): TEACHING SLIDE SET January 2013; used with permission. SAMA: Short acting anticholinergic SABA: Short acting beta2 agonist LAMA: Long acting anticholinergic LABA: Long acting beta2 agonist ICS: Inhaled corticosteriods The evidence on the pharmacologic management can be summarized as follows: Bronchodilators Regular treatment with long-acting bronchodilators is more effective and convenient than short acting (Level A). Regular and as-needed use of short acting beta2-agonists improve FEV1 and symptoms (Evidence B). Long acting inhaled beta2 agonists (Formoterol and salmeterol) significantly improve FEV1, lung volumes, dyspnea, health related quality of life and exacerbation (Evidence A). Salmeterol reduces the rate of hospitalizations (Evidence B). Indacaterol is a newer once daily beta2 agonist with a duration of action of 24 hours. The bronchodilator effect is significantly greater than that of formoterol and salmeterol and similar to tiotropium (Evidence A). Indacaterol has significant effects on breathlessness, health status and exacerbation rate (Evidence B). As this drug is a relatively newer agent, providers will want to continue to watch the literature for reports on it. Oral therapy is slower in onset and has more side effects than inhaled treatment (Level A). Inhaled products, which are absorbed quicker and possess less enduring side effects, are preferred.

7 Bronchodilators Bronchodilator effects of short acting anticholinergics last 8 hours and Tiotropium has a duration of more than 24 hours (Level A). Tiotropium (Spiriva) is preferred as it reduces exacerbations and related hospitalizations, improves symptoms, and health status (Level A). Short term combination therapy using formoterol and tiotropium has been shown to have a bigger impact on FEV1, than the single components (Evidence B). Combinations of short acting beta2 agonists and anticholinergics are also superior compared to either medication alone in improving FEV1 and symptoms (Evidence B). Individual provider judgment and patient preferences play a large role in determining whether to pursue combination therapy. Methylxanthines In these drugs, toxicity is dose related, with the therapeutic ratio small and most of the benefit occurring only when near-toxic doses are given. There is evidence of modest bronchodilator effect compared to placebo with theophylline (Evidence A) but it is not recommended if other bronchodilator drugs are available and affordable. Overall, theophylline is less effective and less well tolerated than today s long-acting bronchodilators. Glucocorticosteroids Regular treatment with inhaled corticosteroid improves symptoms, lung function and quality of life, and reduces the frequency of exacerbations in COPD patients with a FEV1< 60% predicted. (Evidence A) An inhaled glucocorticosteroid combined with a long acting β2 agonist is more effective than the individual components in improving lung function and health status and reducing exacerbations in patients with moderate (Evidence B) to very severe COPD (Evidence A). Phosphodiesterase-4 Inhibitors (Roflumilast) Roflumilast reduces moderate and severe exacerbations treated with corticosteroids by 15-20% in patients with chronic bronchitis, severe to very severe COPD, and a history of exacerbation (Evidence A). The effects on lung function are also seen when roflumilast is added to long acting bronchodilators (Evidence A) whereas the effects on patient related outcomes and particularly exacerbations remains controversial. Side effects reported have included weight loss, unexpected diarrhea, behavioral disturbances, and depression. Other Resources for the Care of COPD Patients At the 2013 Institute for Evidence-Based Care Knowledge in Motion annual conference, a superb presentation on engaging patients in smoking cessation was offered. Dr. Michael B. Steinberg of the Tobacco Dependence Program at Rutgers Robert Wood Johnson Medical School presented: The Latest Evidence for Effective Tobacco Dependence Treatment. This program was recorded and is available at Other videotaped programs from the conference include offerings on health coaching and evidence for use of APNs. While you are on the site, check out the variety of other educational resources available. Recorded Webinars for 2013 that carry continuing education credits include: POLST, Heart Failure Update, Motivational Interviewing for Behavioral Health Change, Medication Adherence, and Home Care Today. New patient education materials are currently being developed. Stay tuned for details!

8 Attention Physicians: Need CMEs? Try This! This issue of Eye on Evidence is now approved for use as an independent study. In order to receive these credits you must complete the attached quiz and evaluation form. When completed, please fax to: Jean Primavera, Meridian Health CME Coordinator Phone: ; Fax: Target Audience: Physicians, physician assistants, APNs, nurses, respiratory therapists, and pharmacists. CME Accreditation Statement: Meridian Health is accredited by the Medical Society of New Jersey to provide continuing medical education for physicians. AMA Credit Designation Statement: Meridian Health designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. Disclosure Statement: Meridian Health, in approving activities for AMA PRA Category 1 Credit, adheres to the ACCME Standards for Commercial Support. SM Meridian Health is responsible for every aspect of the activity it certifies. Faculty and/or planners in a position to control content are expected to disclose relevant financial commercial relationships related to the activity. If a conflict is identified, it is Meridian Health s responsibility to initiate a mechanism to resolve the conflict. The CME enduring activity is in effect for 1 year after release of the newsletter.

9 Meridian Health CME Post-Activity Evaluation Name: (Please print) Professional Title: M.D./D.O. Other (Please Specify) Dept.: CME Activity: Eye on Evidence Newsletter, Special Edition COPD 2013 Location: Online or document Activity Date: NA Speaker(s): NA 1. Do you intend to make changes or apply learnings to your practice as a result of this educational activity? Yes, I plan to make changes Yes, I m considering changes No, I already practice these recommendations If Yes, describe two things you intend to try or do differently as a result of this educational activity: No, I don t think this applies to my practice 2. Identify the major strengths of this educational activity: (check all that apply) Speaker (s) Networking Other: Discussions Support materials Clinical Case Presentations Demos/Hands-on Knowledge gained Case Vignettes 3. Was this educational activity appropriate for your level of training? Yes No (Describe) 4. Were the educational activity s objectives met? Yes No (Describe) The reader should be able to demonstrate knowledge of current evidence care related to quality issues addressed in the newsletter. 5. What additional education and training would be helpful to your practice? 6. Other comments: 7. Was this educational activity free of commercial bias? Yes No (Describe) The editor, K. Russell-Babin, and all planners involved with this educational activity have nothing to disclose.

10 CME Quiz Questions Name: (Please print) Dept.: Please answer these questions T for True and F for false. 1. Indacterol is a well established drug for the management of COPD. 2. The stages of COPD play a greater role in the combination assessment of COPD risk. 3. Theophylline is a first line therapy for COPD. 4. Oral therapy is slower in onset and has more side effects than inhaled treatment. 5. A B quadrant patient is high risk, low symptoms.