Improving Outcomes in COPD. Improving Outcomes in COPD 4/4/2018

Transcription

1 Updates 2018 Neil MacIntyre MD Duke University Durham NC. Barnes PJ. N Engl J Med. 2000;343:

2 COPD spectrum Proximal predominant (large airways) mucus gland hypertrophy (cough/sputum) reduced respiraty drive airway hyper-reactivity Distal predominant (small airways/alveoli) dyspnea - active respiraty drive reduced DLCO COPD spectrum table COPD: the clinical spectrum COPD is a systemic disease Chronic airway inflammation spills inflammaty cytokines into the circulation ASCVD Renal insufficiency Neuro-myopathy Osteoposis Cachexia, debility may be product of this Emphysema Bronchitis Resp Care. 2006; 51: COPD natural histy depends on tobacco exposure/sensitivity 2

3 Proption of 1965 Rate 4/4/2018 COPD Projected to Be the Third-Leading Cause of Death by 2020 COPD: Direct Cost Proption of Rate, Percentage Change in Age-Adjusted Death (US) $20 $18 $16 $14 $12 Nursing Home Care* Home Health Care* Physician Services 1.5 $10 Hospital Care 1.0 $8 $6 Prescription Drugs % -64% -35% +163% -7% Conary Heart Disease Stroke Other CVD COPD All Other Causes Global Initiative f Chronic Obstructive Lung Disease teaching slide kit. Available at: $4 $2 $0 COPD Mbidity and Mtality: 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases. NIH/NHLBI. May EXPOSURE TO RISK FACTORS Diagnosis of COPD AND/ OR SPIROMETRY SYMPTOMS sputum cough dyspnea wheezing Adapted with permission from the GOLD web site. Available at: Spirometry COPD: the spirogram Nmal Obstructed Restricted 3

4 Risk (GOLD Classification of Airflow Limitation) Risk (Exacerbation histy) 4/4/2018 Global Obstructive Lung Disease (GOLD) Constium Staging Spirometry can miss emphysema In COPDgene, 357 of 858 smokers with nmal spirometry had emphysema on CT Symptoms/function as imptant as FEV1 on survival BODE: Dyspnea, 6MWT, BMI, FEV1 GOLD 2017: Combined Assessment of COPD Diagnose COPD Spirometry not enough Radiology (hyperinflation, emphysema) and DLCO alternate diagnostic tools Two components determine severity of disease Symptom assessment Risk of exacerbations CAT = COPD assessment test; mmrc = modified Medical Research Council. Global Initiative f Chronic Obstructive Lung Disease Accessed March 6, Global Strategy f Diagnosis, Management and Prevention of COPD Combined Assessment of COPD (C) (A) mmrc 0-1 CAT < 10 Symptoms (mmrc CAT sce)) (D) (B) mmrc > 2 CAT > 10 >

5 GOLD )Diagnose 2) Obstruction Severity 3) Impact GOLD Guidelines 2017 Guided by impact not physiology Global Strategy f Diagnosis, Management and Prevention of COPD Manage Stable COPD: Non-pharmacologic Patient Group Essential Recommended Depending on local guidelines A Smoking cessation (can include pharmacologic treatment) Physical activity Flu vaccination Pneumococcal vaccination B, C, D Smoking cessation (can include pharmacologic treatment) Pulmonary rehabilitation Physical activity Flu vaccination Pneumococcal vaccination 2013 Global Initiative f Chronic Obstructive Lung Disease Current Inhaled Medications f COPD Medication Brand Usual Starting Dose Duration β 2 -Agonists Sht-acting Albuterol ProAir, Proventil, Ventolin 2 puffs q 4-6 hrs PRN 4-6 h Levalbuterol Xopenex HFA 2 puffs q 4-6 hrs PRN 4-6 h Pirbuterol Maxair Autohaler 2 puffs q 4-6 hrs PRN 5 h Long-acting Fmoterol Fadil Aerolizer, Perfomist, Brovana 1 inhaled capsule bid 12+ h Indacaterol Arcapta Neohaler 1 inhaled capsule daily 24+ h Salmeterol Serevent Diskus 1 puff bid 12+ h HFA = hydrofluoalkane. Accessed April 3, Cazzola M, et al. Drugs Today. 2011;106: Accessed April 3, PL Detail- Document, Inhalers f COPD. Pharmacist s Letter/Prescriber s Letter. August Current Inhaled Medications f COPD Cont d Medication Brand Usual Starting Dose Duration Anticholinergics Sht-acting Ipratropium bromide Atrovent 2 puffs qid 6-8 h Long-acting Aclidinum Tudza Pressair 1 puff bid 24+ h Tiotropium bromide Spiriva Handihaler 1 inhaled capsule daily 24+ h Combination Bronchodilats Albuterol/ipratropium Combivent 2 puffs q 4-6 hrs PRN 4-6 h Umeclidinum/Vilanterol Ano Ellipta 1 puff daily 24 h * NEW: Titropium/olodaterol (Stiolto) Accessed April 3, Salmon M, et al. J Pharmacol Exp Ther. 2013;345(2): Slack RJ, et al. J Pharmacol Exp Ther. 2013;344(1): PL Detail-Document, Inhalers f COPD. Pharmacist s Letter/Prescriber s Letter. August

6 Current Inhaled Medications f COPD Cont d Medication Brand Usual Starting Dose Duration Inhaled Cticosteroids Budesonide Pulmict Flexhaler 1-2 puffs bid 12 h Fluticasone Flovent HFA 1-2 puffs bid 12 h Beclomethasone QVAR 1-2 puffs bid 12 h Combination Inhalers Fmoterol/Budesonide Symbict 2 puffs bid 12 h Fluticasone/Salmeterol Advair Diskus Advair HFA 1 puff bid 2 puffs bid Fluticasone/Vilanterol Breo Ellipta 1 puff daily 24 h HFA = hydrofluoalkane; PDE4 = phosphodiesterase 4. PL Detail-Document, Inhalers f COPD. Pharmacist s Letter/Prescriber s Letter. August Accessed April 3, Slack RJ, et al. J Pharmacol Exp Ther. 2013;344(1): h The latest compounds and fmulations LABAs Oladaterol SMI (Stiverdi) LAMAs Glycopyronium DPI (Seebri) Umeclidium DPI (Incruse) LABA/ICS Fmoterol/beclamethasone MDI and DPI (Fostair) Fmoterol/mometasone MDI (Dulera) The latest compounds and fmulations LAMA/LABA Fmoterol/aclidinium DPI (Genuair) Fmoterol/glycopyrronium MDI* (Bevespi) Indacaterol/glycopyronium DPI (Ultibro) Oladaterol/tiotropium SMI (Stiolto) LAMA/LABA/ICS Stay tuned Trelegy Ellipta Current Oral Medications f COPD Medication Brand Usual Starting Dose Duration Cticosteroids Methylprednisolone Prednisolone Prednisone PDE4 Inhibit 4-48mg/day depending on disease and response 5-60mg/day depending on disease and response 5-60mg/day depending on disease and response h h h Roflumilast Daliresp One 500 mcg tablet daily 17+ h * co-suspension technology HFA = hydrofluoalkane; PDE4 = phosphodiesterase 4. Using Oral Cticosteroids: a toolbox. Pharmacist s Letter/Prescriber s Letter. 2010;26(5): Accessed April 3, Global Strategy f Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy (Medications in each box are mentioned in alphabetical der, and therefe not necessarily in der of preference.) Other Management Issues Patient A B C D Recommended First choice SAMA prn SABA prn LAMA LABA ICS + LABA LAMA ICS + LABA and/ LAMA Alternative choice LAMA LABA SABA and SAMA LAMA and LABA LAMA and LABA LAMA and PDE4-inh. LABA and PDE4-inh. ICS + LABA and LAMA ICS+LABA and PDE4-inh. LAMA and LABA LAMA and PDE4-inh. Oxygen Rest/episodic Targets? SpO2>88% crect? Nocturnal NIV f hypercapnia (high pressure) Lancet Resp Med 2014; Sept 2: 298 JAMA 2017;317:2177 Lung volume reduction procedures Surgery vs bronchoscopic Action plan f AECOPD Bronchodilats/antibiotics/steroids/hot line 6

7 Percentage Crectly Diagnosed With Obstructive Lung Disease 4/4/2018 Barriers Clinician barriers Proper diagnosis/staging/prescribing per guidelines Patient barriers Understanding complex medication regimens Adherence to treatment plans (both pharmaceutical and non-pharmaceutical) System barriers Costs of medications Clinical suppt structures Clinical COPD Is Just The Tip Of The Iceberg COPD Often Unrecognized During Hospitalization. 2 Million severe SUBCLINICAL COPD *Repeated exacerbations and hospitalizations Mannino. MMWR Surveill Summ. 2002;51(6): Million Dx? Millions at risk Mild Moderate Severe Very Severe Reproduced with permission. Zaas D et al. Chest. 2004;125: Admission Diagnosis Discharge Diagnosis SPR Perfmance Spirometry: HMO PCE Perfmance Pharmacotherapy: Cticosteroids (HMO) Commercial Medicaid Medicare Commercial Medicaid Medicare HMO = health maintenance ganization. 7

8 PCE Perfmance Barriers Pharmacotherapy: Bronchodilats (HMO) Commercial Medicaid Medicare Clinician barriers Proper diagnosis/staging/prescribing per guidelines Patient barriers Understanding complex medication regimens Adherence to treatment plans (both pharmaceutical and non-pharmaceutical) System barriers Costs of medications Clinical suppt structures LABA Adherence Cost Differences Between Baseline and Followup N = 1014 COPD in health plan given new LABA Prescription filling over 1 year: >80% 26% 60-70% 14% 40-50% 20% 20-30% 21% <20% 19% LAMA/LABA LABA/ICS LAMA/LABA/ICS CHEST 2014, Abstract 12014b Asche CV, et al. Int J Chron Obstruct Pulmon Dis. 2012;7: Why aren t patients adherent? Lack of understanding of imptance Maintenance vs rescue Ineffective use of devices Breathing maneuvers, device operation Costs The donut hole and drugs running several hundred $/month Barriers Clinician barriers Proper diagnosis/staging/prescribing per guidelines Patient barriers Understanding complex medication regimens Adherence to treatment plans (both pharmaceutical and non-pharmaceutical) System barriers Costs of medications Clinical suppt structures 49 8

9 System Barriers Access to clinicians Priity scheduling Hot lines Home visits Education Discharge planning Medications Follow-up plans Pulmonary rehabilitation centers Barriers to pulm rehab Less than 2% of COPD patients use PR (COPD 2014; July 1) Why not me? Limited number of programs Cost/reimbursement issues (now CMS reimbursed) Logistics (transpt, timing) Motivation 52 Clinical Suppt Structure Access to clinicians Hot lines Home visits Education Discharge planning Medications Follow-up plans Rehabilitation centers 9