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1 MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) IN ADULTS Summary statement: How does the document support patient care? Staff/stakeholders involved in development: Job titles only Division: Department: Responsible Person: Author: For use by: Purpose: This document supports: Standards and legislation This guideline supports staff in prescribing treatment for patients with a diagnosis of COPD. Lead Pharmacist Medicine Respiratory Consultants Specialist Nurses - Respiratory Medicine Respiratory Lead Consultant - COPD Lead Pharmacist Medicine (SRH) All clinical staff at Western Sussex Hospitals NHS Foundation Trust managing patients with COPD. This document outlines the Trust s treatment guidelines for Chronic Obstructive Pulmonary Disease in adults. Global Initiative for Chronic Obstructive Lung Disease s (GOLD) Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease 2017 Report Key related documents: Approved by: Divisional Governance/Management Group Medicines Optimisation Committee (MOC) Approval date: January 2018 Ratified by Board of Directors/ Committee of the Board of Directors Ratification Date: For completion by the Compliance Team. For completion by the Compliance Team. Expiry Date: January 2021 Review date: January 2021 If you require this document in another format such as Braille, large print, audio or another language please contact the Trusts Communications Team Reference Number: To be added by the Library

2 Version date Author Status Comment 1.0 May 2017 Lead Pharmacist Medicine (SRH) Superceded 2.0 January Lead Pharmacist Medicine (SRH) Addition of Trelegy Ellipta device Page 2 of 10

3 MANAGEMENT OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) IN ADULTS INTRODUCTION Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. The chronic airflow limitation that is characteristic of COPD is caused by a mixture of small airways disease (e.g., obstructive bronchiolitis) and parenchymal destruction (emphysema), the relative contributions of which vary from person to person. The most common respiratory symptoms include dyspnoea, cough and/or sputum production. These symptoms may be under-reported by patients. The main risk factor for COPD is tobacco smoking but other environmental exposures such as biomass fuel exposure and air pollution may contribute. Besides exposures, host factors predispose individuals to develop COPD. These include genetic abnormalities, abnormal lung development and accelerated aging. COPD may be punctuated by periods of acute worsening of respiratory symptoms (exacerbations). In most patients, COPD is associated with significant concomitant chronic diseases, which increase its morbidity and mortality. These local guidelines are based on the Global Initiative for Chronic Obstructive Lung Disease s (GOLD) Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease 2017 Report and incorporate the Coastal West Sussex Formulary and local supporting services. DIAGNOSIS & ASSESSMENT COPD should be considered in any patient who has dyspnoea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease. Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation. The goals of COPD assessment are to determine the severity of the disease, including the severity of airflow limitation, the impact of disease on the patient s health status, and the risk of future events (such as exacerbations, hospital admissions, or death), in order to guide therapy. Page 3 of 10

4 Classification of severity of airflow obstruction The GOLD classification of airflow limitation severity in COPD is shown below. Spirometry should be performed after the administration of an adequate dose of at least one short-acting inhaled bronchodilator in order to minimize variability. In patients with FEV 1 /FVC < 0.70: GOLD 1: Mild FEV1 > 80% predicted GOLD 2: Moderate 50% < FEV1 < 80% predicted GOLD 3: Severe 30% < FEV1 < 50% predicted GOLD 4: Very Severe FEV1 < 30% predicted Assessment of symptoms In the past, COPD was viewed as a disease largely characterized by breathlessness and the Modified British Medical Research Council (mmrc) Questionnaire was developed as a measure of dyspnoea. The mmrc relates well to other measures of health status and predicts future mortality risk. Score mmrc Grade 0 mmrc Grade 1 mmrc Grade 2 mmrc Grade 3 mmrc Grade 4 Description of breathlessness I only get breathless with strenuous exercise. I get short of breath when hurrying on the level or walking up a slight hill. I walk slower than people of the same age on the level because of breathlessness, or I have to stop for breath when walking on my own pace on the level. I stop for breath after walking about 100 meters or after a few minutes on the level. I am too breathless to leave the house or I am breathless when dressing or undressing. However, it is now recognized that COPD impacts patients beyond just dyspnoea. For this reason, a comprehensive assessment of symptoms is recommended using measures such as the COPD Assessment Test (CAT) (see appendix 1). The revised combined COPD assessment The GOLD refined ABCD assessment tool combines the severity of airflow limitation, an assessment of dyspnoea using mmrc or symptoms using CAT and also their history of exacerbations (including prior hospitalisations). This will lead to a group outcome of either A,B,C or D which can be used for selecting the most appropriate pharmacological management. Page 4 of 10

5 PHARMACEUTICAL MANAGEMENT Pharmacologic therapy for COPD is used to reduce symptoms, reduce the frequency and severity of exacerbations and improve exercise tolerance and health status. Inhaled Therapy Treatment of COPD should follow the GOLD 2017 treatment algorithm which utilises the GOLD groups previously mentioned: Group C Group D 2 or 1 leading to hospital admission Further exacerbation(s) LAMA + LABA LABA + ICS Further exacerbation(s) LAMA + LABA + ICS Persistent symptoms/ further exacerbation(s) LAMA LAMA LAMA + LABA LABA + ICS Exacerbation history Group A Group B Continue, stop or try alternative class of bronchodilator LAMA + LABA 0 or 1 (not leading to hospital admission) Evaluate effect A bronchodilator Persistent symptoms A long-acting bronchodilator (LABA or LAMA) mmrc 0-1 CAT < 10 Symptoms mmrc 2 CAT 10 : Preferred treatment Combining bronchodilators with different mechanisms and durations of action may increase the degree of bronchodilation with a lower risk of side-effects compared to increasing the dose of a single bronchodilator. Choice of drug depends on device suitability and dosing regimen. Inhaler technique and compliance should be checked prior to changes in medication. Short-acting bronchodilators (SABA or SAMA) Salbutamol MDI 100mcg - 2 puffs PRN Ipratropium MDI 20mcg - 2 puffs PRN Page 5 of 10

6 Long-acting beta 2 -agonists (LABA) Formoterol Easyhaler 12 mcg - 1 puff BD Serevent MDI (salmeterol) 25mcg - 2 puffs BD Long-acting muscarinic antagonists (LAMAs) Incruse Ellipta (Umeclidinium) 55mcg - 1 puff OD Spiriva Handihaler (Tiotropium) 18mcg - 1 puff OD Spiriva Respimat (Tiotropium) 2.5mcg - 2 puffs OD Eklira Genuair (Aclidinium) 322mcg - 1 puff BD Seebri Breezhaler (Glycopyrronium) 44mcg 1 puff OD Combination Long-acting muscarinic antagonists & Long-acting beta 2 -agonists (LAMA+LABA) Anoro Ellipta (Umeclidinium / vilanterol) 55/22mcg - 1 puff OD Duaklir Genuair (Aclidinium / formoterol) 340/12mcg - 1 puff BD Spiolto Respimat (Tiotropium / olodaterol) 2.5/2.5mcg - 2 puffs OD Ultibro Breezhaler (Glycopyrronium / indacterol) 54/110mcg - 1 puff OD Combination Long-acting beta 2 -agonists & Inhaled corticosteroids (LABA+ICS) Relvar Ellipta (Fluticasone furoate / vilanterol) 92/22mcg - 1 puff OD Fostair MDI (Beclometasone / formoterol) 100/6mcg - 2 puffs BD Fostair Nexthaler (Beclometasone / formoterol) 100/6mcg - 2 puffs BD Symbicort Turbohaler (Budesonide / formoterol) 400/12mcg - 1 puff BD Seretide Accuhaler (Fluticasone / salmeterol) 500 mcg - 1 puff BD Combination Long-acting beta 2 -agonists, Long-acting muscarinic antagonists & Inhaled corticosteroids (LABA, LAMA+ICS) Trelegy Ellipta (Fluticasone furoate / umeclidinium / vilanterol) 92/55/22mcg - 1 puff OD See Coastal West Sussex Formulary ( for full list of approved drugs. (Green = first line choice) Other Maintenance Treatments Theophylline Consider if patient remains symptomatic despite, or intolerant of, inhaled therapy. Prescribe by brand name. Care in prescribing in the elderly and smokers due to altered pharmacokinetics, comorbidities and interactions. Reduce dose if macrolide or fluroquinolone antibiotics are prescribed. Mucolytic Consider a trial of carbocisteine 750mg TDS for 1-2 weeks in patients with productive cough. Continue only if symptoms improve at 1.5g daily in divided doses. Do not routinely prescribe to reduce exacerbations. Oral Corticosteroids Maintenance use is not normally recommended. Patients with advanced COPD may require maintenance therapy if corticosteroids cannot be successfully withdrawn following exacerbation. Page 6 of 10

7 Osteoporosis prophylaxis Patients treated with long-term oral corticosteroid therapy (intended for longer than 3 months) or frequent short courses of prednisolone should be monitored for the development of osteoporosis and given appropriate prophylaxis. Patients over the age of 65 should be started on prophylactic treatment, without monitoring. Refer to local osteoporosis guidelines. Nebulisers In most cases bronchodilator therapy is best administered using a hand-held inhaler device (including a spacer device if appropriate). Patients with distressing or disabling breathlessness despite maximal therapy should be considered for nebuliser therapy. Secondary care assessment is advised before consideration of nebulised therapy. Vaccination Pneumococcal vaccination and annual influenza vaccination should be offered to all COPD patients. Smoking Cessation All patients who smoke should be encouraged to stop and offered help to do so at every opportunity. Stopping smoking at any age reduces the rate of FEV 1 decline in patients with COPD. Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates. To access smoking cessation services within Coastal West Sussex go to Long term Oxygen Therapy (LTOT) Assess the need for LTOT in patients with: very severe airflow obstruction, cyanosis, polycythaemia, peripheral oedema, raised JVP, oxygen saturations less than or equal to 92% on air. Consider referral of patients with severe airflow obstruction. LTOT should be used for a minimum of 15 hours per day. Smokers should be warned of the risk of fire. MANAGING EXACERBATIONS An exacerbation of COPD is defined as an acute worsening of respiratory symptoms that result in additional therapy. Exacerbations of COPD can be precipitated by several factors. The most common causes are respiratory tract infections. Treatment Short-acting inhaled beta2-agonists with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation. Oral corticosteroids i.e. prednisolone 30mg OD, can improve lung function, oxygenation and shorten recovery time. Duration of therapy should not be more than 5-7 days. Page 7 of 10

8 Antibiotics, when indicated, can shorten recovery time and reduce the risk of early relapse and treatment failure. Duration of therapy should be 5-7 days. See Microguide for formulary choice. PULMONARY REHABILITATION Pulmonary rehabilitation significantly increases exercise capacity, reduces dyspnoea and improves health related quality of life in COPD. Consider referral in all motivated patients post admission for exacerbation of COPD plus outpatients on optimum drug therapy with activities of daily living limited by breathlessness (normally mmrc grade 2 or higher) or decreasing exercise tolerance. SUPPORTIVE, PALLIATIVE, END-OF-LIFE & HOSPICE CARE Opioids should be used when appropriate for the palliation of breathlessness in endstage COPD unresponsive to other medical therapy. Consider the use of benzodiazepines, tricyclic antidepressants and oxygen. Refer to palliative care teams via the End of Life Hub (ECHO) option 3. Consider dietetic advice if the BMI is high or low. If BMI is below 20 give nutritional supplements and encourage exercise to augment the effects of supplementation. Pay attention to weight changes in older patients (especially >3kg). COPD COMMUNITY RESPIRATORY SERVICE COPD Community Respiratory Service Adur, Arun and Worthing localities Chanctonbury locality Chichester and Regis localities Oxygen review service Referral via OneCall - Telephone: Fax: Referral via OneCall - Telephone: Fax: No service available Pulmonary rehabilitation Referral via OneCall - Telephone: Fax: No service available Referral via OneCall - Telephone: Fax: British Lung Foundation Breathe Easy Support Groups Patient Education and peer support. Direct patients to Page 8 of 10

9 Appendix 1 COPD Assessment Test (CAT) Page 9 of 10

10 Appendix 2 Management of COPD in Adults Quick Reference Guide Page 10 of 10