06/11/2017. COPD What s new? Learning outcomes. COPD why is the correct diagnosis important?

Transcription

1 COPD What s new? Learning outcomes Professor Peter R Bremner University of Notre Dame St John of God Murdoch Current issues in management of COPD Identification of COPD Initiation of treatment COPD exacerbations Non-pharmacological interventions Device selection WHAT ARE THE CURRENT ISSUES IN COPD MANAGEMENT? ACCURATE COPD DIAGNOSIS IS OFTEN LATE DIAGNOSIS Delayed diagnosis, misdiagnosis, underuse of spirometry 1-4 UNDERUSE OF PULMONARY REHABILITATION INAPPROPRIATE USE OF INHALED CORTICOSTEROIDS 6 COPD IS UNDERDIAGNOSED 50% of all symptomatic COPD remains undiagnosed 1 WHY? Signs and symptoms may be subtle 2 Attributed to ageing or other conditions 3 Underuse of spirometry as a diagnostic tool 4 COPD IS OFTEN MISDIAGNOSED 5 Commonly misdiagnosed as asthma, and vice versa 6,7 Delayed use of appropriate interventions for COPD Remember to take into consideration comorbid conditions such as ischaemic heart disease, osteoporosis, metabolic syndrome, lung cancer, mental health etc, which significantly impact on prognosis References: 1. Lung Foundation Australia. Position paper on the use of COPD screening devices for targeted COPD case finding in community settings.lungfoundation.com.au. 2. Lung Foundation Australia. COPD: The statistics. lungfoundation.com.au. 3. Walters JA et al. Prim Care Respir J 2011; 20: Soriano JB et al. Lancet 2009; 374: Johnston K, Grimmer-Somers K. Physiother Can 2010; 62: Data on file: HCN Update on COPD and Asthma Diagnosis and Management Q Data from MedicalDirector General Practice Research Network (GPRN). 3 References: 1. Lung Foundation Australia. COPD: The statistics. lungfoundation.com.au. 2. Mapel D et al. Int Journal of COPD 2011: 6; Price D et al. Prim Care Respir J 2011; 20: Soriano JB et al. Lancet 2009; 374: Walters JA et al. Prim Care Respir J 2011; 20: Tinkelman DG et al. J Asthma 2006; 43: Jones RC et al. Respir Res 2008; 9: COPD why is the correct diagnosis important? COPD why is the correct diagnosis important? 40% of patients in general practice with a label of COPD have never had spirometry, and of these, 41% don t actually have the COPD 16% of non-respiratory admissions to hospital have undiagnosed COPD Of all acute exacerbations of COPD admitted to hospital, 34% represent a new or first diagnosis In reality, less than 5% of all patients in general practice have had spirometry Of admissions to hospital with an exacerbation of COPD as the discharge diagnosis: - 15% had normal spirometry, - 12% couldn t perform spirometry correctly - 21% didn t have spirometry, - only 56% had COPD Do patients hospitalized with COPD have airflow obstruction? Wu et al. Chest 2017:

2 FEV 1 (% of value at age 25 years) 06/11/2017 WHY USE SPIROMETRY? SPIROMETRIC DIAGNOSIS OF COPD Diagnosis based on symptoms and history alone is likely to miss up to 50% of COPD cases 1 Spirometry is the gold standard for evaluating airflow limitation 3 COPD IS DEFINED AS: Airflow obstruction that doesn t reverse to normal COPD usually has some degree of reversibility *As classified by Australian COPD-X guidelines References: 1. Walters J et al. Respir Med 2008; 102: Johns DP et al. Spirometer users and buyers guide Yang I et al, on behalf of Lung Foundation Australia. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease. Version 2.44, December Reference: 1. Yang I et al, on behalf of Lung Foundation Australia. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease. Version 2.44, December IDENTIFYING AT-RISK PATIENTS SCREENING SYMPTOM CHECKLIST Identify at-risk individuals for further testing and clinical diagnosis Time-course of FEV 1 decline in COPD COPD should be considered in any patient aged 35 years and over who meets one or more of the following criteria: 1 Smoker or ex-smoker Occupational exposure to dust, gas or fumes Cough Short of breath Experiences chest tightness or wheeze Smoked regularly and susceptible to the effects Onset of symptoms Never smoked or not susceptible to smoke Stopped smoking at age 45 years Has frequent chest infections At least once in every adult patient, even in the absence of symptoms 25 Severe disability Stopped smoking at age 65 years Reference: 1. Lung Foundation Australia. Position paper on the use of COPD screening devices for targeted COPD case finding in community settings Death Age (years) Adapted from Fletcher C and Peto R. BMJ1977;1: COPD WHAT INITIAL TREATMENT? Pharmacologic interventions Goal is symptom relief via bronchodilation Inhaled short-acting bronchodilators, as monotherapy or in combination, are first option for treatment of mild COPD 1-3 A STEPWISE APPROACH IS RECOMMENDED 1 MILD FEV % predicted few symptoms breathless on moderate exertion recurrent chest infections little or no effect on daily activities MODERATE FEV % predicted increasing dyspnoea breathless walking on level ground increasing limitation of daily activities cough and sputum production exacerbations requiring oral corticosteroids and/or antibiotics SEVERE FEV 1 <40% predicted dyspnoea on minimal exertion daily activities severely curtailed experiencing regular sputum production chronic cough exacerbations of increasing frequency and severity SAMAs Short-acting muscarinic receptor antagonists SABAs Short-acting ß 2 -adrenoreceptor agonists CHECK DEVICE USAGE TECHNIQUE AND ADHERENCE AT EACH VISIT Short-acting reliever medication: Short-acting ß 2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) Symptom relief (some agents have been LAMA AND/OR LABA OR LAMA/LABA shown to also prevent exacerbations) Exacerbation prevention When FEV 1 <50% predicted AND LABA/ICS 2 exacerbations in 12 months References: 1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for diagnosis, management, and prevention of COPD Yang I et al, on behalf of Lung Foundation Australia. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease. Version 2.44, December Lung Foundation Australia. Stepwise management of stable COPD. February Reference: 1. Lung Foundation Australia. Stepwise management of stable COPD. February

3 COPD WHAT MAINTENANCE TREATMENT? Pharmacologic interventions Goal is sustained bronchodilation Inhaled long-acting bronchodilators, as monotherapy or in combination, are the cornerstone of maintenance treatment for all stages of COPD 1-3 ICS Use in COPD Not currently indicated as monotherapy There is now a global drive to reduce (inappropriate) use of ICS in COPD LAMAs Long-acting muscarinic receptor antagonists LABAs Long-acting ß 2 -adrenoreceptor agonists Several studies, including the WISDOM and INSTEAD randomised controlled trials, have demonstrated that it is possible to withdraw ICS without a corresponding increase in exacerbation frequency References: 1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for diagnosis, management, and prevention of COPD Yang I et al, on behalf of Lung Foundation Australia. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease. Version 2.44, December Lung Foundation Australia. Stepwise management of stable COPD. February ICS withdrawal is now recognised by the GOLD strategy as an appropriate treatment approach in selected patients Reference: 1. Data on file: HCN Update on COPD and Asthma Diagnosis and Management Q Data from MedicalDirector General Practice Research Network (GPRN). 14 ICS Use in COPD who not to withdraw GUIDELINES ARE NOT IMPLEMENTED CONSISTENTLY: AUSTRALIAN PRESCRIBING DATA A subgroup with an elevated peripheral eosinophil count may respond to ICS and may be at a greater risk of exacerbation if not on ICS (the optimal cut-off to define this subgroup is unclear) ICS are an option for those with 2 or more exacerbations in the last year Approximately 70% of COPD patients treated with a maintenance therapy are prescribed a LABA/ICS 1 A stratified, longitudinal cohort providing de-identified general practice data from a nationally representative cohort of over 400 Australian GPs. This database provides insight into clinical activity in Australia. GPs have identified patients as having a diagnosis of COPD. Reference: 1. Data on file: HCN Update on COPD and Asthma Diagnosis and Management Q Data from MedicalDirector General Practice Research Network (GPRN). 15 Reference: 1. Data on file: HCN Update on COPD and Asthma Diagnosis and Management Q Data from MedicalDirector General Practice Research Network (GPRN). 16 Other options in COPD Inhaled Corticosteroids in the Australian Market Mucolytics May reduce the likelihood of hospitalisation when given in high doses and may reduce exacerbations Oxygen Only if hypoxia is present (SaO 2 < 90%) when stable. No evidence to support O 2 in exercise induced desaturation below 90% if not hypoxic at rest Macrolides Reduce the rate of COPD exacerbations in some patients and the proportion of patients who experience an exacerbation (uncertainty about adverse effects of chronic therapy and patient selection) 17. 3

4 NEW OPTIONS FOR BRONCHODILATION IN COPD Potential LAMA / LABA / ICS combinations for COPD Available LAMA/LABA therapies Trade names of potential LAMA / LABA / ICS combinations (PBS listed at August 2014) Inhalers per patient* Dosing frequency Seebri Breezhaler / Symbicort Rapihaler (or Turbuhaler ) + or types 101,105,107 Once daily 107 / twice daily 101,105 Seebri Breezhaler / Seretide Accuhaler (or MDI) + or types 102,107 Once daily 107 / twice daily 102 Spiriva / Symbicort Rapihaler (or Turbuhaler ) Once daily 100 / types 100,101,105 + or twice daily 101,105 Ultibro Breezhaler (indacaterol/glycopyrronium) Brimica Genuair (eformoterol/aclidinium) Anoro Ellipta (vilanterol/umeclidinium) Spiolto Respimat (tiotropium/olodaterol) Spiriva / Seretide Accuhaler (or MDI) + or types 100,102 Once daily 100 / twice daily 102 Ultibro, Breezhaler are registered trademarks of Novartis Pharmaceuticals AG. Anoro, Ellipta are registered trademarks of the GlaxoSmithKline group of companies. Brimica, Genuair are registered trademarks of Almirall, S.A. References: 1. Price D et al. Prim Care Respir J 2013; 22: Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for diagnosis, management, and prevention of COPD Yang IA et al. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD Lung Foundation Australia. Stepwise management of stable COPD. February Bretaris Genuair / Symbicort Rapihaler (or Turbuhaler ) Bretaris Genuair / Seretide Accuhaler (or MDI) types63,101,105 + or Both twice daily63,101,105 + or Both twice daily 63,102 types 63,102 Stepwise management of stable COPD 1 The complete COPDX guidelines are available from the Lung Foundation of Australia at ROLE OF NON-PHARMACOLOGIC INTERVENTIONS Early implementation of non-pharmacologic interventions can slow COPD progression and improve quality of life 1 STOP Smoking cessation Vaccination Pulmonary rehabilitation Adapted from: 1. Lung Foundation. Stepwise Management of Stable COPD. February Stepwise Management of Stable COPD. Reproduced with permission from the publisher, Lung Foundation. Australia. Reference: 1. Yang I et al, on behalf of Lung Foundation Australia. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease. Version 2.44, December WHAT IS PULMONARYREHABILITATION? Pulmonary rehabilitation is a comprehensive, multidisciplinary program encompassing exercise training, education and support 1 WHAT ARE THE BENEFITS OF PULMONARY REHABILITATION IN COPD? Benefits reported from pulmonary rehabilitation include: 1,2 Exercise training (key component) Psychosocial support Education & behavioural interventions Components of pulmonary rehabilitation 2-4 Breathing techniques Nutritional interventions Reduced HOSPITAL ADMISSIONS NNT = 4* Reduced DEPRESSION AND ANXIETY Reduced MORTALITY NNT = 6* The minimum length of an effective rehabilitation program is 6 weeks If exercise training is maintained at home, health status remains above pre-rehabilitation levels 3 23 References: 1. Spruit M, et al. Am J Respir Crit Care Med 2013; 188, e Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for diagnosis, management, and prevention of COPD Frith P. A manual for pulmonary rehabilitation in Australia, Yang I et al, on behalf of Lung Foundation Australia. The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease. Version 2.44, December *Based on Cochrane reviews of pulmonary rehabilitation for COPD. MCID, minimum clinically important difference. NNT, number needed to treat. References: 1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for diagnosis, management, and prevention of COPD Puhan MA et al. Cochrane Database Syst Rev 2011; (10):CD Global Initiative for Chronic Obstructive Lung Disease (GOLD). Pocket guide to COPD diagnosis, management and prevention

5 Percent Mortality 06/11/2017 IMMUNISATION REDUCES THE RISKS ASSOCIATED WITH INFLUENZA & PNEUMOCOCCAL INFECTION Definition of a COPD exacerbation Pneumococcal vaccine (13vconjugate) is recommended for those with: Moderate severe COPD who have never received pneumococcal immunisation; a first dose of 13vconjugate is recommended at diagnosis followed by the 23vPPV at one month and an additional doses pf 23vPPV at 5 years. For older adults who have already received an aged-based first dose of 23vPPV at aged 65 years (nonindigenous) or 50 years (indigenous), a single revaccination dose of 13vconjugate is recommended a minimum of 12 months after the previous dose An exacerbation of COPD is an acute event characterised by a worsening of the patient s respiratory symptoms that is beyond normal day-today variations (and leads to a change in medication) 1 For MILD COPD only use the 23vPPV only References: 1. Abramson M et al. COPD-X concise guide for primary care. Brisbane. Lung Foundation Australia. Version 3.02, August Yang I et al, on behalf of Lung Foundation Australia. The COPD- X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease. Version 2.44, December GOLD 2015 Recognition and treatment of exacerbations is critical - immediate and long-lasting consequences 3 8 Diagnosis of COPD exacerbation 12 Identify exacerbation and cause Physical examination Complementary tests (spirometry, VBG/ABG, oximetry, chest X-ray, ECG) Contribute to long-term decline in lung function 3 Reduce physical activity 4 Have a profound effect on quality of life 5 Often require hospital admission for treatment of respiratory failure 6 Associated with an increased risk of death, particularly if hospital admission is required 7 Have high socioeconomic costs, largely due to hospitalisation 8 3. Donaldson GC et al. Thorax Donaldson GC et al. Am J Respir Crit Care Med Wilkinson TM et al. Am J Respir Crit Care Med COPDX Guidelines Soler-Cataluna JJ et al. Thorax Blasi F et al. PLoS One 2014 Be certain of the COPD diagnosis Document increased respiratory symptoms Clinical suspicion COPD exacerbation Assess severity Differential diagnosis (chest X-ray, ECG) Pneumonia Pulmonary embolism Heart failure Arrhythmia Physical deconditioning Pneumothorax Pleural effusion Ischaemic heart disease Adapted from Soler-Cataluña JJ et al. Emergencias Soler-Cataluña JJ et al. Emergencias 2013 Exacerbations are associated with increased pulmonary and systemic inflammation 2 Bacteria Systemic inflammation Cardiovascular comorbidity TRIGGERS EFFECTS Viruses Exacerbation symptoms Inflamed COPD airways Greater airway inflammation Pollutants Bronchoconstriction oedema, mucus Expiratory flow limitation Dynamic hyperinflation Adapted from Wedzicha JA, Seemungal TA. Lancet Mortality following ED Visit for COPD exacerbation 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 5% 9% 11% 16% 23% 32% 39% 30 Days 60 Days 90 Days 180 Days 1 Year 2 Years 3 Years Time Following Admission 2. Wedzicha JA, Seemungal TA. Lancet

6 Survival probability 06/11/2017 Kaplan-Meier survival function for the cohort of 73,106 patients from the time of their first ever hospitalisation for a COPD exacerbation over the 17- year follow-up period. COPD exacerbation 1 Inpatient mortality is 3.8% 12 month mortality is 23% Acute event mortality Myocardial infarction (MI) 2,3 Inpatient mortality less than 3% for NSTEMI and STEMI 5 year mortality is 15% 1. COPD-X Plan. X: Manage exacerbations Australian Institute of Health and Welfare Cardiovascular series no. 31. Cat. no.47. Canberra: AIHW. 3. AIHW. d= Increased exacerbations have been associated with COPD mortality risk 21 Severe acute exacerbations of COPD were found to have an independent negative impact on patient prognosis with greatest mortality risk for those patients with three or more acute COPD exacerbations (HR 4.13, 95% CI 1.80 to 9.41) Kaplan-Meier survival curves by frequency of exacerbations in patients with COPD 21 Group A: no exacerbations Group B: 1 2 exacerbations requiring hospital management Group C: 3 exacerbations Time (months) A p< B p=0.069 Adapted from Soler-Cataluña et al :Data from from prospective study in a cohort of 304 male patients with stable COPD recruited in 1998 and followed for five years to investigate whether severe acute exacerbations of COPD (those requiring hospital management) exert a direct and independent effect on the survival of COPD patients C p< Optimising treatment for acute exacerbation of COPD 6 Bronchodilators Corticosteroids Antibiotics Controlled oxygen therapy Ventilatory assistance Signs and symptoms Airflow limitation Excess sputum production Airway inflammation Infection Hypoxia Hypercapnia Acidosis 33 CI=confidence interval; COPD = chronic obstructive pulmonary disease; HR=hazard ratio Reference. 21. Soler-Cataluña JJ et al. Thorax 2005;60: COPDX Guidelines 2014 Systemic corticosteroids reduce the severity of and shorten recovery from exacerbations 15 Controlled oxygen delivery is indicated only for hypoxia Oral corticosteroids are recommended for ease of administration 15 Administer oxygen via nasal cannula, aiming for SaO 2 of 88 92% Understand the poor relationship between SOB and hypoxaemia Prescribe oral corticosteroids (prednisolone mg or equivalent, taken in the morning) for 5-7 days and then stop; tapering the dose is confusing and rarely necessary 15 Avoid use of high-flow oxygen 15 May lead to hypoventilation and acute respiratory failure COPDX Concise Guide for Primary Care COPDX Concise Guide for Primary Care

7 Comprehensive follow up is required following discharge from hospital 15 Individualised discharge plans may reduce hospital length of stay and readmission rates 15 Pharmacological interventions following an exacerbation The aim of pharmacological treatment may be to treat symptoms (i.e. breathlessness) or to prevent deterioration (either by decreasing exacerbations or by reducing decline in QOL) or both A stepwise approach is recommended, irrespective of disease severity, until adequate control has been achieved Mild Moderate Severe CHECK DEVICE USAGE TECHNIQUE AND ADHERENCE AT EACH VISIT - Up to 90% of patients don t use devices correctly SHORT-ACTING RELIEVER MEDICATION: salbutamol or terbutaline or ipratropium bromide Hospital discharge plans should be shared with the primary care team, preferably within 24 hours of discharge 15 Discharged patients should be reviewed by a member of the primary care team within 7 days of discharge 15 Patients with chronic cough/ongoing sputum production should be monitored closely and taught airway clearance techniques 15 SYMPTOM RELIEF: Long acting antimuscarinic (tiotropium or glycopyrronium bromide) and/or long acting beta 2agonists (salmeterol, eformoterol or indacaterol # ). This may also help to prevent exacerbations. Once a long acting antimuscarinic is commenced, ipratropium bromide should be discontinued. EXACERBATION PREVENTION: (When FEV 1 < 50% predicted AND patient has had 2 or more exacerbations in the previous 12 months) inhaled glucocorticoids combined with long acting beta 2agonist (fluticasone/salmeterol or budesonide/eformoterol). LABA monotherapy (eformoterol, salmeterol or indacaterol) should be ceased once combination therapy (ICS/LABA) is initiated. 15. COPDX Concise Guide for Primary Care 2014 Adapted from Lung Foundation Australia : #Indacaterol should not be used in asthma or mixed airways disease. A differential diagnosis should be made to exclude asthma or mixed airways disease before initiating indacaterol; FEV 1=forced expiratory volume in one second; ICS=inhaled corticosteroids; LABA=long acting beta 2agonist 38 References: 36. Lung Foundation Australia. Stepwise Management of Stable COPD. Lung Foundation Australia. February 2014 Assessing device technique Inhaled Corticosteroids in the Australian Market Whenever possible, assess then re-assess device technique, and document prominently in you records Incorrect inhaler technique is astonishingly common (up to 94% of patients with COPD). No device is immune to this problem Poor inhaler technique is not surprising, as few doctors know how to use puffers correctly themselves Teaching correct technique can takes on average 2 minutes of your time Device choices: consider patient ability more than patient preference and aim for one type of device if using multiple drugs / puffers 15. MDI COPDX = metered Concise dose Guide inhalers for Primary Care UP TO 94% OF ASTHMA AND COPD PATIENTS INCORRECTLY USE THEIR INHALER DEVICE 1,2 Correct inhaler technique is essential Adherence and inhaler technique should be assessed at every visit 3 1 Patient demonstrates inhaler technique 2 Demonstrate correct technique highlighting steps that need correction Refer to Notebook for common errors of inhaler device use 3 Patient re-demonstrates inhaler technique repeat until all steps performed correctly Patient s adherence to COPD management strategy can be affected by: Skill and physical ability with inhaler technique Use of multiple inhalers Videos of correct inhaler technique for a range of devices can be found on: The National Asthma Council website: The Lung Foundation website: 41 References: 1. Lavorini F et al. Respir Med 2008; 102: Melani AS et al. Respir Med 2011; 105: National Asthma Council. Australian Asthma Handbook. Version 1.1. April

8 Learning outcomes Thank you Current issues in management of COPD Identification of COPD Initiation of treatment COPD exacerbations Non-pharmacological interventions Device selection IMMUNISATION REDUCES THE RISKS ASSOCIATED WITH INFLUENZA & PNEUMOCOCCAL INFECTION IMMUNISATION REDUCES THE RISKS ASSOCIATED WITH INFLUENZA & PNEUMOCOCCAL INFECTION Annual influenza immunisation 1,2 WHO WHEN All patients with COPD Immunise in early autumn A second immunisation in winter will increase antibody levels Regular pneumococcal immunisation 1,2 Pneumococcal polysaccharide vaccine: 23-valent (23vPPV; Pneumovax 23); 13-valent (Prevenar 13 ) WHAT WHO WHEN All patients with COPD Refer to COPD-X Concise Guide for schedule Booster after age 65 Annual influenza immunisation recommended 1,2 Influenza immunisation reduces the risk of exacerbations, hospitalisation and death in patients with COPD All patients with COPD should receive influenza vaccine immunisation Immunise in early autumn; a second immunisation in winter increases antibody levels Regular pneumococcal immunisation recommended, with a booster after age 65 1,2 Pneumococcal polysaccharide vaccine, 23-valent (23vPPV; Pneumovax 23) is highly effective in preventing invasive bacteraemic pneumococcal pneumonia in immunocompetent adults, although there is no direct evidence of its efficacy in preventing pneumococcal exacerbations of COPD References: 1. Abramson M et al. COPD-X concise guide for primary care. Brisbane. Lung Foundation Australia. Version 3.02, August Yang I et al, on behalf of Lung Foundation Australia. The COPD- X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease. Version 2.44, December References: 1. Abramson M et al. COPD-X concise guide for primary care. Brisbane. Lung Foundation Australia. Version 3.02, August Yang I et al, on behalf of Lung Foundation Australia. The COPD- X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease. Version 2.44, December