COPD The New Epidemic. Peter Lin MD CCFP Director Primary Care Initiatives Canadian Heart Research Centre

COPD The New Epidemic Peter Lin MD CCFP Director Primary Care Initiatives Canadian Heart Research Centre

Conflict Disclosure Information Speaker: Dr. Peter Lin Title of Talk: COPD The New Epidemic Financial Disclosure Company Grants / Research Support Speakers Honorarium Consulting Fees Patents Other None Astrazeneca, BMS, Takeda Boeringher Ingelheim, Abbott Eli Lilly, Amgen, Mylan, Janssen Forest Laboratories, J&J, Merck, Novartis, Pfizer, Servier, Sanofi None None None

Mitigating Potential Bias Only published data will be presented in this program and recommendations will be based on published Guidelines

Learning Objectives: By the end of this workshop you will be able to: 1. Make appropriate diagnosis 2. Understand appropriate testing 3. Be able to incorporate guidelines into the management of your patients 4. Understand the role of new therapies for the management of your patients

Percent Change in Age-Adjusted Death Rates, U.S., 1965 1998 (Proportion of 1965 Rate)

Air trapping

Mr. CO 76 year old man Short of breath Had Negative Cardiac workup Smoker 40 pk years Coughs most days some sputum Meds: ARB, Statin, ASA, Vitamins

Global Strategy for Diagnosis, Management and Prevention of COPD Diagnosis of COPD SYMPTOMS shortness of breath chronic cough sputum EXPOSURE TO RISK FACTORS tobacco occupation indoor/outdoor pollution SPIROMETRY: Required to establish diagnosis 2013 Global Initiative for Chronic Obstructive Lung Disease

Focus on Vital Capacity (VC) 12

Spirometry: Normal Trace Showing FEV 1 and FVC 5 FVC Volume, liters 4 3 2 1 FEV 1 = 4L FVC = 5L FEV 1 /FVC = 0.8 1 2 3 4 5 6 Time, sec 2013 Global Initiative for Chronic Obstructive Lung Disease

Spirometry: Mr. CO 5 Normal 4 Volume, liters 3 2 1 FEV 1 = 1.8L FVC = 3.2L FEV 1 /FVC = 0.56 Obstructive < 0.70 1 2 3 4 5 6 Time, seconds 2013 Global Initiative for Chronic Obstructive Lung Disease

Mr. CO Walking can t keep up with his wife

Assessing Disability in COPD

Mr. CO FEV1 is 70% predicted

Global Strategy for Diagnosis, Management and Prevention of COPD Classification of Severity of Airflow Limitation in COPD* based on FEV 1 GOLD 1: Mild GOLD 2: Moderate GOLD 3: Severe GOLD 4: Very Severe FEV 1 > 80% predicted 50% < FEV 1 < 80% predicted 30% < FEV 1 < 50% predicted FEV 1 < 30% predicted *Based on Post-Bronchodilator FEV 1 2013 Global Initiative for Chronic Obstructive Lung Disease

Global Strategy for Diagnosis, Management and Prevention of COPD Classification of Severity of Airflow Limitation in COPD* based on FEV 1 GOLD 1: Mild Mr. CO FEV1 = 70% FEV 1 > 80% predicted GOLD 2: Moderate 50% < FEV 1 < 80% predicted GOLD 3: Severe GOLD 4: Very Severe 30% < FEV 1 < 50% predicted FEV 1 < 30% predicted *Based on Post-Bronchodilator FEV 1 2013 Global Initiative for Chronic Obstructive Lung Disease

Mr. CO 5 years he had 3 exacerbations

What is the impact of exacerbations on mortality? 50% of COPD patients are dead within 4 years of being admitted for first time with COPD 1 A= No Exacerbations B= 1-2 Exacerbations C= > 3 Exacerbations 1.Suissa S, Dell Aniello S, Ernst P. Thorax. doi: 10.1136/thorax.jnl-2011-201518, 2.Soler-Cataluna JJ, et al. Thorax. 2005;60:925-931.

Suissa S et al. Thorax 2012;67:957-963

Daily rates of death (per 10 000 per day) in the 90-day period after onset of severe chronic obstructive pulmonary disease exacerbation. Suissa S et al. Thorax 2012;67:957-963 Copyright BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.

LAMA vs Placebo for Exacerbation 80 * Probability of exacerbation (%) 60 40 20 Hazard ratio: 0.86 CI: 0.81-0.91 *p<0.001 No. at risk 0 0 6 12 18 24 30 36 42 48 Month Tiotropium Placebo 2986 3006 1996 1815 1486 1284 1223 1010 983 776 838 634 709 545 610 460 26 21 Tashkin DP, et al. N Engl J Med. 2008;359:1543-1554.

LAMA vs LAMA + LABA Formoterol + Tiotropium Change from baseline in trough FEV 1 (ml) 250 200 150 100 50 0 Trough FEV 1 : Change from baseline * n=108 n=118 n=127 n=121 n=106 n=121 n=121 n=129 Week 4 Week 8 Week 12 Last visit * * Mean change in symptom score 0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 Total COPD Symptom Score * AM * PM AM/PM average * Formoterol (12 µg b.i.d.) + tiotropium (18 µg o.d.) Tiotropium (18 µg o.d.) *p<0.05; p<0.001 vs. tiotropium; sum of scores for dyspnea (0 = none to 4 = severe), wheezing, cough, and chest ghtness (0 = none to 3 = very uncomfortable). Tashkin DP, et al.: COPD 2009; 6(1):17 25.

TORCH ICS vs LABA vs Combo Calverley PMA et al. N Engl J Med 2007;356:775-789

LAMA vs LAMA + ICS + LABA 0.4 0.3 62% reduction in rate of severe exacerbation Ratio: 0.38 (95% CI: 0.25 0.57) P < 0.001 BUD/FORM + TIO PBO + TIO Exacerbations/patient 0.2 0.1 0.0 0 15 30 45 60 75 90 Poisson regression Days since randomisation BUD/FORM=budesonide/formoterol (320/9 μg bid); PBO = placebo; TIO = tiotropium (18 μg od) Welte T, et al. Am J Respir Crit Care Med. 2009;180:741-750.

Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD GOLD FEV1 4 3 ICS (C) + LABA or LAMA ICS + LABA (D) and/or LAMA >2 <50% Predicted Exacerbations 2 1 SAMA prn (A) or SABA prn LABA (B) or LAMA 1 0 mmrc 0-1 CAT < 10 2013 Global Initiative for Chronic Obstructive Lung Disease Symptoms mmrc > 2 CAT > 10

Treatment of Stable COPD 2017 Global Initiative for Chronic Obstructive Lung Disease

Bronchodilator LAMA or LABA 2 Bronchodilators LAMA + LABA Bronchodilators + ICS LAMA + LABA + ICS

Pharmacotherapy Indicated for COPD in Canada BRONCHODILATORS SHORT ACTING BETA 2 AGONISTS LONG ACTING BETA 2 AGONISTS SHORT ACTING ANTICHOLINE RGICS LONG ACTING ANTICHOLINERGICS Umeclidinium (bromide) INCRUISE Ellipta 62.5 mcg CORTICOSTERIODS/LONG ACTING BETA 2 AGONISTS Budesonide/Formoterol (fumarate) ANTICHOLINERGICS AND LONG ACTING BETA 2 AGONISTS Ipratropium (bromide)/ Salbutamol (sulfate) Glycopyrronium (bromide)/ Indacaterol (maleate) Umeclidinium (bromide)/ Vilanterol (trifenatate) Tiotropium (bromide)/ Olodaterol (hydrochloride) Aclidinium (bromide)/ Formoterol (fumarate) COMBIVENT Respimat 20/100 mcg Chart not representative of all approved COPD medications Canada. INSPIOLTO Respimat 2.5/2.5 mcg www.hc-sc.gc.ca accessed June 24, 2015 DUAKLIR Genuair 400/ 12 mcg

Treatments for COPD Abbreviation Full name Examples Brand (Device) ICS Inhaled corticosteroid Budesonide Fluticasone Proprionate Fluticasone Furoate Pulmicort (Turbuhaler) Flovent (Diskus) (Ellipta) LAMA LAAC Long-acting anticholinergic (also known as long-acting muscarinic antagonist) Tiotropium Glycopyrronium Aclidinium Bromide Umeclidinium Spiriva (Respimat) Seebri (Breezhaler) Tudorza (Genuair) Incruse (Ellipta) Formoterol Oxeze (Turbuhaler) LABA Long-acting beta 2 agonist Salmeterol Indacaterol Vilanterol Serevent (Diskus) Onbrez (Breezhaler) (Ellipta) Olodaterol Striverdi (Respimat) SABA Short-acting beta 2 agonist Salbutamol Terbutaline Ventolin (Diskus) Bricanyl (Turbuhaler) SAMA Short-acting antimuscarinic Ipratropium Atrovent 34

Treatments for COPD Abbreviation Full name Examples Brand (Device) ICS Inhaled corticosteroid Budesonide Fluticasone Proprionate Fluticasone Furoate Pulmicort (Turbuhaler) Flovent (Diskus) (Ellipta) LAMA LAAC Long-acting anticholinergic (also known as long-acting muscarinic antagonist) Tiotropium Glycopyrronium Aclidinium Bromide Umeclidinium Spiriva (Respimat) Seebri (Breezhaler) Tudorza (Genuair) Incruse (Ellipta) LABA SABA Device Long-acting beta 2 agonist Efficacy Safety Short-acting beta 2 agonist Formoterol Salmeterol Indacaterol Vilanterol Olodaterol Salbutamol Terbutaline Oxeze (Turbuhaler) Serevent (Diskus) Onbrez (Breezhaler) (Ellipta) Striverdi (Respimat) Ventolin (Diskus) Bricanyl (Turbuhaler) SAMA Short-acting antimuscarinic Ipratropium Atrovent 39

1 Adapted from : Newman SP, et al. Lung Deposition of fenoterol and flunisolide delivered using a novel device for inhaled medicine: Comparison of Respimat with conventional metereddose inhalers with and without spacer devices. Chest1998;113: 957-963.

DPI (Diskus) Slide the lever away from you as far as it will go Breathe out until lungs are empty Place the mouthpiece in mouth and close lips firmly around it Breathe in as fast & as hard as you can until lungs are full Hold breath for 10s Breathe out Adapted from asthmameds.ca

Respimat

Turbuhaler

Devices Green & Go Red & Done Feedback on successful inhalation Audible click when patient is inhaling sufficiently Control window turns red when inhalation is complete Tudorza Genuair Product Monograph, 2013

Treatments for COPD Abbreviation Full name Examples Brand (Device) ICS Inhaled corticosteroid Budesonide Fluticasone Proprionate Fluticasone Furoate Pulmicort (Turbuhaler) Flovent (Diskus) (Ellipta) LAMA LAAC Long-acting anticholinergic (also known as long-acting muscarinic antagonist) Tiotropium Glycopyrronium Aclidinium Bromide Umeclidinium Spiriva (Respimat) Seebri (Breezhaler) Tudorza (Genuair) Incruse (Ellipta) LABA SABA Device Long-acting beta 2 agonist Efficacy Safety Short-acting beta 2 agonist Formoterol Salmeterol Indacaterol Vilanterol Olodaterol Salbutamol Terbutaline Oxeze (Turbuhaler) Serevent (Diskus) Onbrez (Breezhaler) (Ellipta) Striverdi (Respimat) Ventolin (Diskus) Bricanyl (Turbuhaler) SAMA Short-acting antimuscarinic Ipratropium Atrovent 49

LAS39: Change from baseline FEV 1 by timepoint over 24 hours at Day 1 *p<0.05 aclidinium vs tiotropium This study alone does not constitute a head-to-head study to support comparative claims of aclidinium vs tiotropium. Beier et al. COPD 2013

Aclidinium reduces COPD exacerbation (any severity) rates (24 weeks): ATTAIN 1.6 Placebo Aclidinium 400 µg BID 1.39 COPD exacerbations (/pt/year) 1.2 0.8 0.4 0.60 0.40 33% p<0.05 0.98 29% p<0.05 0.0 Healthcare Resource Utilization criteria EXACT criteria Reproduced with permission Jones et al. CHEST 2012

Canadian RWE A retrospective observational propensity-matched cohort study Healthcare utilisation in the first year after initiating ICS/LABA therapy Courses of oral steroids/year 0.66 0.79 0.85 (0.72, 1.00) ED visits/year 0.16 0.23 0.75 (0.58, 0.97) Hospital admissions/year 0.11 0.21 0.61 (0.47, 0.81) Addition of a tiotropium prescription/year 1.63 2.01 0.71 (0.57, 0.89) In Canada, 5255 COPD patients were treated with an ICS/LABA before matching 3969 (76%) patients in this cohort used FLU/SAL 36% had exacerbations pre-index More bud/form vs. flu/sal pats. had a first ICS/LABA initiated by a specialist (8% more) Antibiotics were not evaluated as a definition of exacerbations Patients were tracked for 1 year Blais L et al. Clin Ther 2010; 32 (7): 1320 These slides have been supplied, on request, by AstraZeneca Scientific Affairs. For complete therapeutic and safety information please consult the SYMBICORT Product Monograph.

COPD Exacerbations BUD/FOR (n=2734) or FLU/SAL (n=2734) Rate ratio (95% CI) All exacerbations 80 109 ** NNT = 3.4 0.74 (0.69, 0.79) Oral steroids 63 85 ** 0.74 (0.68, 0.81) Antibiotics 38 54 ** BUD/FOR 0.70 (0.66, 0.75) Hospitalisations 15 21 ** NNT = 16 SAL/FLU 0.71 (0.65, 0.78) Emergency visits 2.7 3.4 * 0.79 (0.71, 0.89) 0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0 Event rate per 100 patient years Adjusted yearly rates of healthcare utilisation events were compared using Poisson regression analysis. **P<0.0001; *P=0.0003 for difference. CI, confidence intervals; BUD/FOR, budesonide/formoterol; FLU/SAL, fluticasone/salmeterol These slides have been supplied, on request, by AstraZeneca Scientific Affairs. For complete therapeutic and safety information please consult the SYMBICORT Product Monograph. Larsson et al. J Intern Med 2013; DOI: 10.1111/joim.12067

Treatments for COPD Abbreviation Full name Examples Brand (Device) ICS Inhaled corticosteroid Budesonide Fluticasone Proprionate Fluticasone Furoate Pulmicort (Turbuhaler) Flovent (Diskus) (Ellipta) LAMA LAAC Long-acting anticholinergic (also known as long-acting muscarinic antagonist) Tiotropium Glycopyrronium Aclidinium Bromide Umeclidinium Spiriva (Respimat) Seebri (Breezhaler) Tudorza (Genuair) Incruse (Ellipta) LABA Device Long-acting beta 2 agonist Efficacy Formoterol Salmeterol Indacaterol Vilanterol Oxeze (Turbuhaler) Serevent (Diskus) Onbrez (Breezhaler) (Ellipta) SABA Safety Short-acting beta 2 agonist Salbutamol Terbutaline Ventolin (Diskus) Bricanyl (Turbuhaler) SAMA Short-acting antimuscarinic Ipratropium Atrovent 54

Pneumonia Risk in COPD Patients (Stratified by ICS Type) Meta analysis of ICS use (studies 1 3 yr duration) Corticosteroid Type Fluticasone (16 studies) Budesonide (7 studies) Mometasone (1 study) Risk Ratio HR (95%CI) 1.67 (1.47-1.89)* 1.19 (0.92-1.53) [ns] 2.00 (0.83-4.81) [ns] 0.1 0.2 0.5 1 2 5 10 Corticosteroid Safer Corticosteroid Harmful *statistically significant increase with fluticasone p<0.0001 [ns] = no statistically significant increase in risk detected The elderly and those with more severe disease and lower FEV1s are at the highest risk of pneumonia. Singh S, Loke YJ. Curr Opin Pulm Med. 2010; 16: 118 122.

Cumulative Pneumonia Rate vs Time Post Index Cumulative pneumonia rate per 100 patients 110 100 90 80 70 60 50 40 30 20 10 0 Fluticasone/salmeterol group Any pneumonia Hospitalised pneumonia Budesonide/formoterol group Any pneumonia Hospitalised pneumonia All pneumonias RR 1.73 (1,57; 1.90) P<0.001 NNT 23 Hospitalised pneumonias RR 1.74 (1,56; 1.94) P<0.001 NNT 34 0 1 2 3 4 5 6 7 8 9 Years Adjusted yearly pneumonia event rates compared using Poisson regression analysis. Janson et al. BMJ 2013;346:f3306 DOI: 10.1136/bmj.f3306 These slides have been supplied, on request, by AstraZeneca Scientific Affairs. For complete therapeutic and safety information please consult the SYMBICORT Product Monograph.

An Immunosuppressant / Infection hypothesis Fluticasone /salmeterol ASL Mucosa/Lung tissue ASL = Airway surface liquid Budesonide Budesonide/GCS-receptor Bacteria Fluticasone Fluticasone/GCS-receptor These slides have been supplied, on request, by AstraZeneca Scientific Affairs. For complete therapeutic and safety information please consult the SYMBICORT Product Monograph. 1. Wedzicha JA et al. AJRCCM 2008 2. Calverley et al. Chest 2011;139:505 3. Patterson C et al Respiratory Research 2012,13:40 4. Ek A et al Allergy (1999). 54: 691 5. Miller-Larsson et al. AJRCCM (2000). 162: 145 6. Johnsson M et al Allergy (1995) 50:s11-14 7. Dalby C, et al. Respir Res (2009); 10:104

Dissolution Time in Airway Fluid Water solubility (μg/ml) Dissolution time (human BAL fluid in vitro) Flunisolide 140 <2 min Triamcinolone 21 n.d. acetonide Budesonide 16 6 min Beclomethasone 17-propionate Fluticasone 17-propionate Beclomethasone dipropionate 16 n.d. 0.16 >8h 0.13 >5h Högger and Rohdewald, Rev Contemp Pharm 1998 n.d.= no data These slides have been supplied, on request, by AstraZeneca Scientific Affairs. For complete therapeutic and safety information please consult the SYMBICORT Product Monograph.

Safety: Hydrolysis of LAMAs Gavaldà et al. 2014 Two major acid and alcohol metabolites are inactive Sentellas et al, 2010 Alberti et al, 2010

ICS + LABA Advair (Diskus) Abbreviation Full name Examples Brand ICS Inhaled corticosteroid Budesonide Fluticasone Proprionate Fluticasone Furoate Pulmicort (Turbuhaler) Flovent (Diskus) (Ellipta) LAMA LAAC Long-acting anticholinergic (also known as long-acting muscarinic antagonist) Tiotropium Glycopyrronium Aclidinium Bromide Umeclidinium Spiriva (Respimat) Seebri (Breezhaler) Tudorza (Genuair) Incruse (Ellipta) Formoterol Oxeze (Turbuhaler) LABA Long-acting beta 2 agonist Salmeterol Indacaterol Serevent (Diskus) Onbrez (Breezhaler) Vilanterol (Ellipta) SABA Short-acting beta 2 agonist Salbutamol Terbutaline Ventolin (Diskus) Bricanyl (Turbuhaler) SAMA Short-acting antimuscarinic Ipratropium Atrovent 61

ICS + LABA Symbicort (Turbuhaler) Abbreviation Full name Examples Brand ICS Inhaled corticosteroid Budesonide Fluticasone Proprionate Fluticasone Furoate Pulmicort (Turbuhaler) Flovent (Diskus) (Ellipta) LAMA LAAC Long-acting anticholinergic (also known as long-acting muscarinic antagonist) Tiotropium Glycopyrronium Aclidinium Bromide Umeclidinium Spiriva (Respimat) Seebri (Breezhaler) Tudorza (Genuair) Incruse (Ellipta) Formoterol Oxeze (Turbuhaler) LABA Long-acting beta 2 agonist Salmeterol Indacaterol Serevent (Diskus) Onbrez (Breezhaler) Vilanterol (Ellipta) SABA Short-acting beta 2 agonist Salbutamol Terbutaline Ventolin (Diskus) Bricanyl (Turbuhaler) SAMA Short-acting antimuscarinic Ipratropium Atrovent 62

ICS + LABA Breo (Ellipta) Abbreviation Full name Examples Brand ICS Inhaled corticosteroid Budesonide Fluticasone Proprionate Fluticasone Furoate Pulmicort (Turbuhaler) Flovent (Diskus) (Ellipta) LAMA LAAC Long-acting anticholinergic (also known as long-acting muscarinic antagonist) Tiotropium Glycopyrronium Aclidinium Bromide Umeclidinium Spiriva (Respimat) Seebri (Breezhaler) Tudorza (Genuair) Incruse (Ellipta) Formoterol Oxeze (Turbuhaler) LABA Long-acting beta 2 agonist Salmeterol Indacaterol Serevent (Diskus) Onbrez (Breezhaler) Vilanterol (Ellipta) SABA Short-acting beta 2 agonist Salbutamol Terbutaline Ventolin (Diskus) Bricanyl (Turbuhaler) SAMA Short-acting antimuscarinic Ipratropium Atrovent 63

LAMA + LABA Anoro (Ellipta) Abbreviation Full name Examples Brand ICS Inhaled corticosteroid Budesonide Fluticasone Proprionate Fluticasone Furoate Pulmicort (Turbuhaler) Flovent (Diskus) (Ellipta) LAMA LAAC Long-acting anticholinergic (also known as long-acting muscarinic antagonist) Tiotropium Glycopyrronium Aclidinium Bromide Umeclidinium Spiriva (Respimat) Seebri (Breezhaler) Tudorza (Genuair) Incruse (Ellipta) Formoterol Oxeze (Turbuhaler) LABA Long-acting beta 2 agonist Salmeterol Indacaterol Serevent (Diskus) Onbrez (Breezhaler) Vilanterol (Ellipta) SABA Short-acting beta 2 agonist Salbutamol Terbutaline Ventolin (Diskus) Bricanyl (Turbuhaler) SAMA Short-acting antimuscarinic Ipratropium Atrovent 64

LAMA + LABA Ultibro (Breezhaler) Abbreviation Full name Examples Brand ICS Inhaled corticosteroid Budesonide Fluticasone Proprionate Fluticasone Furoate Pulmicort (Turbuhaler) Flovent (Diskus) (Ellipta) LAMA LAAC Long-acting anticholinergic (also known as long-acting muscarinic antagonist) Tiotropium Glycopyrronium Aclidinium Bromide Umeclidinium Spiriva (Respimat) Seebri (Breezhaler) Tudorza (Genuair) Incruse (Ellipta) Formoterol Oxeze (Turbuhaler) LABA Long-acting beta 2 agonist Salmeterol Indacaterol Serevent (Diskus) Onbrez (Breezhaler) Vilanterol (Ellipta) SABA Short-acting beta 2 agonist Salbutamol Terbutaline Ventolin (Diskus) Bricanyl (Turbuhaler) SAMA Short-acting antimuscarinic Ipratropium Atrovent 65

LAMA + LABA Stiolto Respimat Abbreviation Full name Examples Brand ICS Inhaled corticosteroid Budesonide Fluticasone Proprionate Fluticasone Furoate Pulmicort (Turbuhaler) Flovent (Diskus) (Ellipta) LAMA LAAC Long-acting anticholinergic (also known as long-acting muscarinic antagonist) Tiotropium Glycopyrronium Aclidinium Bromide Umeclidinium Spiriva (Respimat) Seebri (Breezhaler) Tudorza (Genuair) Incruse (Ellipta) Formoterol Oxeze (Turbuhaler) LABA Long-acting beta 2 agonist Salmeterol Indacaterol Vilanterol Serevent (Diskus) Onbrez (Breezhaler) (Ellipta) Olodaterol Striverdi (Respimat) SABA Short-acting beta 2 agonist Salbutamol Terbutaline Ventolin (Diskus) Bricanyl (Turbuhaler) SAMA Short-acting antimuscarinic Ipratropium Atrovent 66

LAMA + LABA Duaklir (Genuair) Abbreviation Full name Examples Brand ICS Inhaled corticosteroid Budesonide Fluticasone Proprionate Fluticasone Furoate Pulmicort (Turbuhaler) Flovent (Diskus) (Ellipta) LAMA LAAC Long-acting anticholinergic (also known as long-acting muscarinic antagonist) Tiotropium Glycopyrronium Aclidinium Bromide Umeclidinium Spiriva (Respimat) Seebri (Breezhaler) Tudorza (Genuair) Incruse (Ellipta) Formoterol Oxeze (Turbuhaler) LABA Long-acting beta 2 agonist Salmeterol Indacaterol Serevent (Diskus) Onbrez (Breezhaler) Vilanterol (Ellipta) SABA Short-acting beta 2 agonist Salbutamol Terbutaline Ventolin (Diskus) Bricanyl (Turbuhaler) SAMA Short-acting antimuscarinic Ipratropium Atrovent 67

Treatments for COPD Abbreviation Full name Examples Brand (Device) ICS LAMA LAAC LABA SABA SAMA Inhaled corticosteroid Long-acting anticholinergic (also known as long-acting muscarinic antagonist) Long-acting beta 2 agonist Short-acting beta 2 agonist Short-acting antimuscarinic Budesonide Fluticasone Proprionate Fluticasone Furoate Tiotropium Glycopyrronium Aclidinium Bromide Umeclidinium Device Efficacy Formoterol Salmeterol Indacaterol Vilanterol Safety Salbutamol Terbutaline Pulmicort (Turbuhaler) Flovent (Diskus) (Ellipta) Spiriva (Respimat) Seebri (Breezhaler) Tudorza (Genuair) Incruse (Ellipta) Oxeze (Turbuhaler) Serevent (Diskus) Onbrez (Breezhaler) (Ellipta) Ventolin (Diskus) Ipratropium Atrovent Bricanyl (Turbuhaler) 68

COPD Risk & Smoking Cessation 1,5,7 Never smoked or not susceptible to smoke FEV 1 (% of value at age 25) Smoked regularly and susceptible to effects of smoke Disability Death Stopped smoking at 45 (mild COPD) Stopped smoking at 65 (severe COPD) Age (years) Fletcher C et al. Br Med J. 1977;1:1645 1648.

Peter COPD Lin MD CCFP Maze Director Primary Care Initiatives Canadian Heart Research Centre Keep COPD in DDx Tools for Assessing Risk Medications: Bronchodilators vs ICS Step up: Single then dual then triple Rx Decide based on: Device, Efficacy, Safety Avoid Exacerbations