COPD and Asthma Update. April 29 th, 2017 Rachel M Taliercio, DO Staff, Respiratory Institute

COPD and Asthma Update April 29 th, 2017 Rachel M Taliercio, DO Staff, Respiratory Institute

What we ll be talking about COPD: diagnosis, management of stable COPD, COPD exacerbations Asthma: diagnosis, comorbidities, management Asthma/COPD Overlap: phenotype, management Smoking cessation: pearls, electronic cigarettes

55 year old male, current smoker (25 pack year history), presents with several months of worsening dyspnea on exertion. Has a chronic cough which he attributes to smoking. Two colds this past year, took him weeks to recover from each episode. Your diagnosis: 1. Asthma 2. COPD 3. Asthma/COPD Overlap 4. Unable to determine

COPD: Spirometry is Required to Make the Diagnosis Assesses lung function by measuring expiratory volumes and flow rates Obtain spirometry on all patients with chronic cough, sputum production or dyspnea

COPD = Fixed Airflow Obstruction Airflow limitation that is irreversible or partially reversible with bronchodilator FEV1/FVC ratio < 0.70 or < LLN FEV1: measure of severity of airflow obstruction Spirometry is not recommended as screening tool

COPD and Smoking Majority of risk for developing COPD is from smoking (~80%) 15 to 20% of smokers develop clinically significant COPD Symptoms typically develop after 20 or more pack years Smokers lose lung function at an accelerated rate Quitting is beneficial at any age, more pronounced in earlier quitters Passive smoke exposure has been implicated as a cause of COPD (affects women > men) Kohansal et al. Am J Respir Crit Care Med 2009;180:3 10

81 year old female, never smoker, presents with several month history of dyspnea on exertion. No associated cough, wheeze or chest tightness. No history of asthma. No history of chronic respiratory illness as a child or adult. Homemaker. No significant second hand smoke exposure.

COPD in Never Smokers Up to 20% of patients with COPD More common in women Typically moderate to severe obstruction Additional risk factors: low BMI, low education level, history of asthma, severe respiratory infections in childhood Occupational exposures: organic dust, biomass fuel Chest 2011; 139(4): 752-763

COPD: Management Goal of treatment: to improve symptoms and exercise capacity, reduce exacerbations and hospitalizations Considerations for initial therapy: Symptoms FEV1 History of exacerbations Past exacerbation history is the best predictor of future flares

63 yo male, former smoker, new diagnosis of COPD. FEV1 75% predicted (mild obstruction). Reports occasional dyspnea. No history of COPD flare. Which of the following is indicated? 1. Short-acting bronchodilator 2. Short-acting bronchodilator and flu vaccine 3. Short-acting bronchodilator, flu vaccine, long-acting bronchodilator (LABA or LAMA) 4. Short-acting bronchodilator, flu vaccine, combination therapy (ICS/LABA)

Short-Acting Bronchodilators (SABA)

Short-Acting Bronchodilators (SAMA)

57 yo female with COPD here to establish care. FEV1 60% predicted (moderate obstruction). Has noticed breathlessness during walking on a flat surface. No h/o flare. What is the recommended first-line inhaled therapy? 1. Short-acting bronchodilator 2. Inhaled steroids 3. Long-acting bronchodilator 4. Long-acting bronchodilator/inhaled steroid combination

COPD: Bronchodilators (BD) are Key Long-Acting Bronchodilators

Same patient, here for six month follow up visit. Went to urgent care two months ago, diagnosed with bronchitis. Given prednisone and antibiotics. Taking Tiotropium daily. Still breathless with activity. What is the best next step? 1. Continue long-acting bronchodilator, add combination therapy (ICS/LABA) 2. Switch from long-acting bronchodilator to combination therapy (ICS/LABA) 3. Switch from long-acting bronchodilator monotherapy to dual BD therapy (LABA/LAMA) 4. Continue long-acting BD and add ICS

FLAME trial LABA/LAMA vs. ICS/LABA 17% reduction in moderate-to-severe exacerbations with dual bronchodilator therapy

Dual Bronchodilators (LABA/LAMA)

COPD: When to Think About Inhaled Steroids Moderate to severe COPD Repeated exacerbations Low quality of life Asthma-COPD Overlap Always in combination with LABA Risks associated with use: Oral candidiasis, hoarseness Skin bruising Pneumonia

Which of the following has been shown to impact survival in COPD? 1. Smoking cessation 2. Oxygen therapy (in patients with severe chronic resting hypoxemia) 3. Maintenance medication 4. 1 and 2 5. All of the above

Pulmonary Rehab Improves dyspnea and exercise capacity Reduces hospitalization and improves QOL in patients with a recent exacerbation What your patients should expect: Exercise training Education Inspiratory muscle training

COPD Exacerbations: Ambulatory Management GOLD 2017: worsening of respiratory symptoms that result in additional therapy Give antibiotics Infection implied in up to 80% of episodes Shortened recovery time, reduces treatment failure, increases time between flares Give oral steroids Improve lung function, trend toward fewer hospitalizations Dosage? Duration? (no more than 10 to 14 days) Anthonisen NR et al. Ann Intern Med 1987;106:196 Wedzicha et al. ERJ 2017; 49: 1600791 Sethi S. Chest 2000;117:380S-385S

COPD Exacerbations: Antibiotic Selection Anzueto A et al. Am J Med Sci 2010; 340(4): 309-318 Used with permission courtesy of Dr. Aboussouan

COPD: When to Refer Disease onset < 40 years old Frequent exacerbations (> 2 or more per year) despite therapy Severe airflow obstruction (FEV1 < 50%) Patients on oxygen therapy Significant comorbidities Considering add-on therapy

Asthma

What percent of study participants with physician-diagnosed asthma had no evidence of current asthma (% of patients in whom asthma was ruled out)? 1. 10% 2. 20% 3. 30% 4. 50% 5. 60% Aaron et al. JAMA. 2017; 317(3): 269-279

Asthma: Diagnosis Chronic airway inflammation shortness of breath, cough, wheezing, chest tightness Variable symptoms (episodic) Variable airflow limitation Symptoms vary over time and in intensity

Airflow Obstruction with Positive Bronchodilator Response

Asthma: Diagnosis Whenever possible, confirm diagnosis before starting controller therapy Clinical urgency or other diagnosis unlikely start empiric treatment Then diagnostic testing within 1 to 3 months

Asthma Triggers

Your patient has a clinical history suggestive of asthma. You order lung function testing and it is normal, no reversibility. What is the best next step? 1. Consider alternative diagnosis 2. Treat empirically for asthma 3. Order methacholine challenge test 4. Check exhaled nitric oxide

Methacholine Challenge Test

Exhaled Nitric Oxide (eno, FENO) > 50 ppb: eosinophilic airway inflammation High eno suggests steroid responsiveness Useful in monitoring inflammation 20% reduction = steroid responsiveness Assessment tool for adherence Not a good diagnostic test for asthma Also elevated in rhinosinusitis/atopy, eosinophilic bronchitis, COPD, eczema

Asthma is Heterogenous

Asthma Phenotypes Allergic asthma Non-allergic asthma Late-onset asthma Asthma with fixed airflow obstruction Asthma with obesity

Your patient has allergic asthma and you tell him the cat is a major trigger. He tells you his girlfriend will break up with him before she gets rid of the cat. Which of the following are strategies to reduce exposure? 1. Remove carpets/hepa filter on vacuum 2. Brush pet outside to remove dander 3. Remove the cat from the bedroom 4. Change your clothes after prolonged exposure to the animal 5. All of the above

Which of the following is the most common cause of uncontrolled asthma: 1. Poor adherence 2. Incorrect inhaler technique 3. Incorrect diagnosis 4. Inadequate therapy 5. Persistent exposure to triggers

Asthma Management: High Value, Low Cost Increase delivery of drug into the lung Increased potency of inhaled steroids Reduction in oropharyngeal candidiasis Toogood et al. AJRCCM 1984; 129: 723-729.

Asthma Management: Anti-Inflammatory is the Standard

Combination Therapy: ICS/LABA

Asthma Management: Additional Therapies Anti-leukotrienes: Montelukast (Singulair ), Zafirlukast (Accolate ), Zileuton (Zyflo ) Biologic agents/monoclonal antibody: Omalizumab (Xolair ), Mepolizumab (Nucala ), Reslizumab (Cinqair ) Long-acting muscarinic antagonist (LAMA): Tiotropium (Spiriva )

Stepwise Approach to Asthma Therapy: Key Points Step 1: consider low dose ICS SABA alone for pts with asthma sxs less than twice/month, no nighttime sxs, no risks/hx flares ICS reduce risk of severe exacerbations Step 2: low dose ICS other options: LTRA, low dose theophylline Before considering step-up to 3 or 4: Check diagnosis, inhaler technique, exposures, adherence

Stepwise Approach to Asthma Therapy: Key Points Step 3: low dose ICS/LABA other options: med/high dose ICS OR low dose ICS + LTRA) Step 4: med/high dose ICS/LABA (add tiotropium) Step 5: refer for add-on treatment Step 3 to 5 reliever therapy: SABA or low dose ICS/LABA

Reddel et al. Eur Respir J 2015; 46: 579-582.

>= 20 : well controlled 16-19 : not well controlled 15 : very poorly controlled Asthma Control Test QualityMetric incorporated, 2002. www.asthmacontrol.com

Asthma Management: Assess for Comorbidities Upper airway disease: chronic rhinosinusitis, nasal polyposis Obstructive sleep apnea GERD (no role for treatment if patient asymptomatic) Paradoxical vocal fold motion (formally known as vocal cord dysfunction) Obesity Depression

Asthma-COPD Overlap Nearly 25% of patients with COPD report history of asthma Features of both: more symptoms, increased rate of exacerbations, more likely hospitalized, more rapid decline lung function Younger, women men, higher BMI, fewer pack years of smoking, greater % African- Americans Compared to COPD alone: similar lung function, less emphysema on imaging Eur Respir J 2014; 44: 341 350

Asthma-COPD Overlap Suggested criteria Age > 40 FEV1/FVC < 0.70 Exposure to cigarette smoke Previous/current history of asthma/atopy Marked bronchodilator response (>400 ml) IgE level > 100 Blood eosinophils > 5% Treatment response is different Early initiation of inhaled corticosteroids is recommended Chest. 2015; doi: 10.1378/chest.15-1055

Your patient is interested in quitting smoking. Which of the following treatment methods has the highest abstinence rate? 1. Nicotine patch 2. Nicotine patch + nicotine gum 3. Buproprion SR (Zyban) 4. Nicotine patch + Buproprion 5. Varencycline (Chantix)

Your patient is overweight and concerned about weight gain after smoking cessation. Which of the following would be a good option? 1. Nicotine patch 2. Nicotine patch + nicotine gum 3. Buproprion SR (Zyban) 4. Nicotine patch + Buproprion 5. Varencycline (Chantix)

Electronic Cigarettes Most popular tobacco product among high school and middle school students Highest prevalence (14%) in young adults 18 to 24 years old

The Power of Advertising Perceived as a tool to quit or reduce smoking Similar efficacy to nicotine replacement therapy

Electronic Cigarettes: Lack of Evidence of Harm Safety Normalization of smoking behavior Gateway to other tobacco products Students identify use of e-cigarettes as a significant factor in being likely to try tobacco products Known pulmonary toxicity FDA now has authority to prohibit sale to minors

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