CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) TREATMENT GUIDELINES Document Description Document Type Service Application Version Guidelines All healthcare professionals(hcps) caring for patients with asthma V10 Ratification date September 2016 Review date March 2018 Lead Author(s) Name Joanne Hamilton Dr M Hopkin Minesh Parbat Position within the Organisation Lead Nurse Respiratory DGNHFT GP & Respiratory Lead Prescribing Advisor Presented for discussion, approval and ratification to Core Policies and Procedures Group Change History Version Date Comments 1.0 September 2005 2.0 January 2008 3.0 September 2009 4.0 September 2010 Updates drug treatment Updates drug treatment and layout Updates drug treatment and layout Updates drug treatment and layout 5.0 July 2014 Updates drug treatment and layout 6.0 July 2015 Updates drug treatment and layout
7.0 September 2015 7.4 8.9 September 2015 September 2016 9.0 September 2016 Updates drug treatment and layout Updates drug treatment and layout (Draft) Final version 9.1 June 2017 Updates drug treatment and layout (Draft) 10.0 June 2017 Final version Link with Care Quality Commission Essential Standards of Quality & Safety Regulation 10, Outcome 16 Assessing & Monitoring the quality of services provision. Regulation13, Outcome 9 Management Of Medicines Link with Trust Purpose and Values statements These guidelines are aimed to improve the health and wellbeing of our local community. They link with values 1-11
Summary Sheet These treatment guidelines have been produced as a quick reference guide for HCPs who manage people with COPD. The guidelines are based on NICE COPD guidelines 2010 and GOLD COPD guidance 2015. These treatment guidelines will help to ensure appropriate, cost effective prescribing for people of all ages, with COPD The treatment guidelines will form part of an asthma education program. They support HCPs with prescribing and should be used in conjunction with the NICE/GOLD guidelines. These guidelines have been widely consulted on since March 2016, including: Dudley Respiratory Group Practice Nurse Mentors Prescribing and Medicines Management Team Presentations to Dudley GPs & Practice Nurses Nurse Consultant These guidelines will be reviewed at least every 2 years or sooner if indicated, by Dudley Respiratory Group or Area Clinical Effectiveness Committee.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) TREATMENT GUIDELINES DIAGNOSIS IS CONFIRMED USING POST BRONCHODILATOR SPIROMETRY RATIO (FEV 1 /FVC x 100) <70% FEV 1 % Predicted NICE 2010 GOLD 2017 80% (+symptoms) MILD 1 50-79% MODERATE 2 30-49% SEVERE 3 <30% VERY SEVERE 4 A FULL CLINICAL HISTORY IS OF PARAMOUNT IMPORTANCE Choose a drug based on the person s symptomatic response and preference, the drug s side effects, potential to reduce exacerbations and cost. Do not use oral corticosteroid reversibility tests to identify patients who will benefit from inhaled corticosteroids. Be aware of the potential risk of developing side effects (including non-fatal pneumonia) in people with COPD treated with inhaled corticosteroids and be prepared to discuss with the patients consider osteoporosis risk see local guidance including FRAX score Ensure all patients have a personal management plan. Smoking cessation is the only intervention that reduces the decline of lung function in COPD. Encourage all patients to stop smoking. Encourage all patients to exercise. If the MRC is 3, or the patient considers themselves functionally disabled, refer to Pulmonary Rehabilitation. Steam Inhalation can prove beneficial Bronchodilators are the cornerstone of treatment for patients with COPD A B C D Low Risk Less Symptoms Low Risk More Symptoms High Risk Less Symptoms High Risk More Symptoms
INHALED THERAPY Adapted fom GOLD 2017 (A B C D) Always Check Compliance & Inhaler technique Assess Breathlessness using MRC and CAT score Prescribe by Brand INTERMITTENT BREATHLESSNESS AND/OR EXERCISE LIMITED Short Acting Bronchodilators or SABA SAMA BREATHLESSNESS and/or one exacerbation A B Long Acting Bronchodilators LAMA (STOP SAMA) or LABA or LAMA/LABA in a combination inhaler (STOP LAMA or LABA IN SEPARATE INHALERS) BREATHLESSNESS with 2 or more EXACERBATIONS C Long Acting Bronchodilators in a Combination Inhaler LAMA/LABA in a combination Inhaler BREATHLESSNESS with 2 or more EXACERBATIONS D Inhaled Corticosteroids LAMA/LABA in a combination Inhaler - (STOP LAMA OR LABA IN SEPARATE INHALERS) or LABA/ICS in a combination Inhaler plus a LAMA - (STOP LABA IN SEPARATE INHALER) When prescribing ICS for patients with COPD assess history of pneumonia and smoking status
Mucolytic Therapy Consider in people with a chronic productive cough and continue use if symptoms improve. Do not routinely use to prevent exacerbations. Carbocisteine capsules or oral liquid: 750mg three times a day for 4 weeks (capsules 375mg: Liquid 250mg/5mls) (If no benefit stop treatment). If beneficial continue with 750mg twice a day. Management of Acute Exacerbations Increase frequency of short acting Bronchodilators use & consider giving via a nebuliser Prednisolone 30mg once daily for 5-7 days Administer antibiotics in accordance with local guidelines (Hyperlink to Antibiotic Guidelines) Oxygen Therapy Assess the need for oxygen therapy Oxygen saturations less than 93% breathing air Refer as per local guidelines (Hyperlink to Oxygen Therapy) ORAL THERAPY (Hyperlink See for to osteoporosis Osteoporosis guidance Guidelines) Corticosteroids Maintenance use of oral corticosteroid therapy in COPD is not normally recommended Some people with advanced COPD may need maintenance oral corticosteroids if treatment cannot be stopped after an exacerbation. Keep the dose as low as possible, monitor for osteoporosis and offer prophylaxis. Theophylline - Prescribe by brand. Offer only after trials of short- and long-acting bronchodilators or to people who can not use inhaled therapy. Theophylline can be used in combination with beta2 agonists and muscarinic antagonists. Take care when prescribing to older people because of pharmacokinetics, comorbidities and interactions with other medications. Reduce Theophylline dose if macrolide or fluroquinolone antibiotics (or other drugs known to interact) are prescribed to treat an exacerbation.
ALWAYS OFFER PATIENTS ADVICE ON Smoking cessation Pulmonary rehabilitation Anxiety & depression Exercise Dietary advice KEY COPD SABA SAMA LABA LAMA ICS FEV 1 GOLD NICE CAT MRC Chronic Obstructive Pulmonary Disease Short Acting B 2 Agonist Short Acting Muscarinic Antagonist Long Acting Beta 2 Agonist Long Acting Muscarinic Antagonist Inhaled Corticosteroid Forced Expiratory Volume in the first second Global Initiative for Chronic Obstructive Lung Disease The National Institute for Health and Care Excellence COPD Assessment Tool Medical Research Council Breathlessness Score
COPD Inhaled Treatment - RECOMMENDED FIRST LINE PRESCRIBE BY BRAND Brand Name SABA LAMA LABA ICS Dosing Regime TDD ICS Short Acting Ventolin MDI 100mcgs Salbutamol 2 puffs as required Bronchodilators Salamol Easibreathe MDI 100mcgs Salbutamol 2 puffs as required Bricanyl Turbohaler 500mcgs Terbutaline 1 puff as required Salbutamol Easyhaler 100mcgs Salbutamol 2 puffs as required TDD BDP Equivalent Long Acting Eklira Genuair 322mcgs Aclidinium Bromide 1 puff twice daily Bronchodilators Spiriva Handihaler 18mcgs Tiotropium 1 puff once daily Formoterol EasyHaler 12mcgs Formoterol 1 puff twice daily Duaklir Genuair 340/12 mcgs Aclidinium Bromide Formoterol 1 puff twice daily Inhaled *Symbicort Turbohaler 400/12mcgs Formoterol Budesonide 1 puff twice daily 800mcgs 800mcgs Corticosteroids *Symbicort MDI 200/6 mcgs Formoterol Budesonide 2 puffs twice daily 800mcgs 800mcgs in a combination **Fostair NextHaler 100/6 mcgs Formoterol Beclometasone ExtraFine 2 puffs twice daily 400mcgs 1000mcgs inhaler (ICS+LABA) **Fostair MDI 100/6 mcgs Formoterol Beclometasone ExtraFine 2 puffs twice daily 400mcgs 1000mcgs *Symbicort is licensed in COPD FEV 1 <70% predicted **Fostair is licensed in COPD FEV 1 <50% predicted TDD Total Daily Dose BDP Beclometasone ICS Inhaled Corticosteroid LABA Long Acting Beta2 Agonist LAMA Long Acting Muscarinic Antagonist SAMA Short Acting Muscarinic Antagonist SABA Short Acting Beta2 Antagonist mcgs micrograms MDI Metered Dose Inhaler
COPD Inhaled Treatment - RECOMMENDED FIRST LINE PRESCRIBE BY BRAND Brand Name SABA LAMA LABA ICS Dosing Regime TDD ICS Short Acting Ventolin MDI 100mcgs Salbutamol 2 puffs as required Bronchodilators Salamol Easibreathe MDI 100mcgs Salbutamol 2 puffs as required Bricanyl Turbohaler 500mcgs Terbutaline 1 puff as required Salbutamol Easyhaler 100mcgs Salbutamol 2 puffs as required TDD BDP Equivalent Long Acting Eklira Genuair 322mcgs Aclidinium Bromide 1 puff twice daily Bronchodilators Spiriva Handihaler 18mcgs Tiotropium 1 puff once daily Formoterol EasyHaler 12mcgs Formoterol 1 puff twice daily Duaklir Genuair 340/12 mcgs Aclidinium Bromide Formoterol 1 puff twice daily Inhaled *Symbicort Turbohaler 400/12mcgs Formoterol Budesonide 1 puff twice daily 800mcgs 800mcgs Corticosteroids *Symbicort MDI 200/6 mcgs Formoterol Budesonide 2 puffs twice daily 800mcgs 800mcgs in a combination **Fostair NextHaler 100/6 mcgs Formoterol Beclometasone ExtraFine 2 puffs twice daily 400mcgs 1000mcgs inhaler (ICS+LABA) **Fostair MDI 100/6 mcgs Formoterol Beclometasone ExtraFine 2 puffs twice daily 400mcgs 1000mcgs *Symbicort is licensed in COPD FEV 1 <70% predicted **Fostair is licensed in COPD FEV 1 <50% predicted TDD Total Daily Dose BDP Beclometasone ICS Inhaled Corticosteroid LABA Long Acting Beta2 Agonist LAMA Long Acting Muscarinic Antagonist SAMA Short Acting Muscarinic Antagonist SABA Short Acting Beta2 Antagonist mcgs micrograms MDI Metered Dose Inhaler
Other Inhaled Treatment on the Formulary - SECOND LINE PRESCRIBE BY BRAND Brand Name SABA LAMA LABA ICS Dosing Regime TDD ICS Glycopyrronium Long Acting Seebri Breezhaler 44mcgs Bromide 1 puff once daily Bronchodilators Onbrez Breezhaler 150 & 300 mcgs Indacaterol 1 puff once daily Serevent Accuhaler 50mcgs Salmeterol 1 puff twice daily Serevent MDI 25mcgs Salmeterol 2 puffs twice daily TDD BDP Equivalent Inhaled Corticosteroids in a combination inhaler (ICS+LABA) Seretide Accuhaler 500/50 mcgs Relvar Ellipta 92/22 mcgs Existing Patients Only Fluticasone Propionate 1 puff twice daily 1000mcgs 2000mcgs Salmeterol Consultation Initiation Only Vilanterol Fluticasone Furoate 1 puff once daily 92mcgs?1000mcgs TDD Total Daily Dose BDP Beclometasone ICS Inhaled Corticosteroid LABA Long Acting Beta2 Agonist LAMA Long Acting Muscarinic Antagonist SAMA Short Acting Muscarinic Antagonist SABA Short Acting Beta2 Antagonist mcgs micrograms MDI Metered Dose Inhaler