Dr Stephen Child General Physician Auckland 14:20-14:40 Secondary Care Perspective
Wheeze Witchery Stephen Child MD, FRACP, FRCPC General Physician Respiratory Interest Director of Clinical Training Auckland District Health Board
Conflict of Interest Speaker Fees - AstraZeneca - Boehringer Ingelheim - Merck Sharp & Dohme - Pfizer - GlaxoSmithKline Chair New Zealand Medical Association Clinical Governance Group Procare PHO/Homecare Medical Treatment Injury Advisor - ACC
Obstruction FEV 1.0 < 0.70 VC FVC 40% 1s
Obstructive Airways Diseases Asthma/COPD Bronchiectasis Allergic Bronchopulmonary Aspergillosis Cystic Fibrosis Sarcoidosis CHF Broncholitis- obliterans ( COP/other ) Allergy/Anaphylaxis Obesity?? Other- Eg: aspiration,fb,etc
Professor Peter J. Barnes, MD National Heart and Lung Institute, London UK
Inflammation in Asthma Acute inflammation Acute or chronic inflammation? Steroid response Chronic Inflammation Structural Changes Time Barnes PJ
GOLD 2011 subtypes CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease; mmrc, modified Medical Research Council questionnaire. GOLD, Global strategy for the diagnosis, management and prevention of COPD, 2013. Available at: http://www.goldcopd.org/guidelines-globalstrategy-for-diagnosis-management.html (accessed February 2013).
Airflow Obstruction Asthma (Reversible) Eosinophils ICS responsive Neutrophils ICS unresponsive COPD (Non-Reversible)
COPD Controversy 1) When ICS? 2) EoS guided treatment? 3) Reduce exacerbation? 4) Which inhaler?
Guideline Summary Asthma COPD 1. SABA prn 2. ICS + SABA 3. ICS + LABA 4. Other 1. SA B.D prn 2. LA B.D 3. ICS if < 50% 4. Other
COPD Cochrane Review - 2007 47 studies n = >13,000 ICS - reduces exac (<50% pred) - improves QOL (marginal) - +/- on FEV1.0 decline - no effect mortality
TORCH Feb 2007 Death Pneumonia Exac/year Placebo 15.2% 12% 1.13 Combination 12.6% 19% 0.85 p=0.052 p=<0.05 p=<0.05
ICS and Pneumonia (Samy Suissa) Thorax Oct 2013 n=163,000 COPD > 55 yrs - 20,000 adm CAP nested case controls Overall, HR = 1.7 - FP = 2.0 - Dose responsive - Beclo = 1.4 - Cessation = drop risk - Bud = 1.2 NNH = 16-22 (* note NNT exac = 14-44)
WISDOM showed no significant difference in mod/sev COPD exacerbations for ICS withdrawal group BUT a 38 ml greater reduction in trough FEV 1 than the ICS continuation group at 18 weeks Tricco AC et al. BMJ Open 2015;5:e009183
COPD - Pred Change FEV1.0 % sput eos
COPD - Eos n = 243 <2% eos >2% eos 20% fail 20% fail Pred 11% fail No Pred 66% fail
COPD exac n=3255 LABA (Vil) LABA + ICS (FF) 2 4 6 >6 Blood Eos %
EOS Reactive Non-smoker Atopy COPD Step 3 EOS Fixed Recurrent exac/infection Add ICS LABA/LAMA +/- Antibiotics Step 4
vol 100/yr 30/yr 30/yr 25 age
COPD - ECLIPSE 38% - >40 ml/yr decline 31% - 21 40 ml/yr decline 23% - +20 - -20 decline/improve 8% - >21 - improve
COPD Exac Cat Chang - Waikato N = 248 COPD exac prospective cohort Day 30 mort 8.8% (17% Trop) (28% BNP) Day 365 mort 17.7% (ECLIPSE = 35 50% mortality 1 year post exac)
4 yr mortality (%) COPD ECLIPSE - Lung attack * >NSTEMI # exac in past year -?Aspirin
COPD ECLIPSE - Lung attack 6 months to return SGRQ to normal 2-3 mls drop per attack
So ICS when.? A. Poor lung function ( < 50% ) B. 2 or more exac. C. Eosinophils???
COPD Mar 1, 2016 LAMA - Tiotropium - Respimat - Handihaler - Umeclindinium - Glycopyrronium LAMA/LABA - Tio/olodaterol - Umeclind/Vilanterol - Glyco/Indacaterol ICS/LABA - Bud/Formot - Flu/Salm - Flu/Vilanterol
Network meta-analysis plots. (A) Exacerbation
Results 112 abstract citations found 97 studies excluded ( not relevant ) = 15 full studies reviewed Further 5 excluded for wrong design, study design, duplicate study or review article + 10 studies from unpublished and manufacturers Total= 20 reports( 23 studies ) = 27,172 pts (19 double blinded )
Exacerbations 16 trials = mod; 19 trials =severe For Moderate exacerbations only: Comb> placebo HR=0.66 Comb> LABA HR=0.82 Comb =LAMA HR 0.92 ( 0.84-1.00 ) No differences for severe exac
Plan 1. SABD 2. LAMA mono 3. a) If SOB LAMA/LABA b) If exac/severe Triple 4. +/- Antibiotics HR 0.93
GOLD 2011 subtypes CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease; mmrc, modified Medical Research Council questionnaire. GOLD, Global strategy for the diagnosis, management and prevention of COPD, 2013. Available at: http://www.goldcopd.org/guidelines-globalstrategy-for-diagnosis-management.html (accessed February 2013).
Are RCT patients the same as real-life patients with obstructive lung disease? Asthma patients eligible for RCT COPD patients eligible for RCT COPD, chronic obstructive pulmonary disease; FEV 1, forced expiratory volume in 1 second; ICS inhaled corticosteroid; RCT, randomised controlled trial; S, smoker; XS, ex-smoker; VAS, visual analogue scale. Herland K et al. Respir Med 2005; 99: 11 9.
COPD - GP 1. Clear recognition / diagnosis 2. Smoking Cessation 3. Antibiotics / steroids prn scripts 4. Acute appointment times CURB 65 / VBG 5. Vaccination
Plan 1. SABD 2. LAMA mono 3. a) If SOB LAMA/LABA b) If exacerbation/severe Triple 4. +/- Antibiotics HR 0.93