Neil MacIntyre MD Duke University Durham NC Current treatment guidelines f COPD focus Barriers to providing optimal treatment Diagnosis of COPD EXPOSURE TO RISK FACTORS AND/ OR SYMPTOMS sputum cough dyspnea wheezing SPIROMETRY. Barnes PJ. N Engl J Med. 2000;343:269-80. Adapted with permission from the GOLD web site. Available at: www.goldcopd.com. COPD: the spirogram Nmal Obstructed Restricted GOLD Staging: FEV/FVC < 0.7, then FEV % pred: Mild >80%, Mod 50-79%, Severe 30-49%, Very Severe <30% GOLD 207: Combined Assessment of COPD Spirometry not enough misses emphysema, s ymptoms, exacerbation risk Three components determine severity of disease Spirometry to assess degree of airflow limitations Symptom assessment Risk of exacerbations CAT = COPD assessment test; mmrc = modified Medical Research Council. Global Initiative f Chronic Obstructive Lung Disease. 204. http://www.goldcopd.g/guidelines-global-strategyf-diagnosis-management.html. Accessed March 6, 204.
Proption of 965 Rate Risk (GOLD Classification of Airflow Limitation) Risk (Exacerbation histy) 9/7/207 Global Strategy f Diagnosis, Management and Prevention of COPD Combined Assessment of COPD GOLD 207 4 (C) (D) > 2 )Diagnose 2) Obstruction Severity 3) Impact 3 2 (A) (B) 0 mmrc 0- mmrc > 2 CAT < 0 CAT > 0 Symptoms (mmrc CAT sce)) COPD natural histy depends on tobacco exposure/sensitivity COPD Projected to Be the Third-Leading Cause of Death by 2020 COPD: Direct Cost Proption of 965-998 Rate, Percentage Change in Age-Adjusted Death (US) $20 3.0 2.5 $8 $6 $4 Nursing Home Care* Home Health Care* 2.0 $2 Physician Services.5 $0 Hospital Care.0 $8 $6 Prescription Drugs 0.5-59% -64% -35% +63% -7% 0.0 Conary Stroke Other CVD COPD All Other Heart Disease Causes Global Initiative f Chronic Obstructive Lung Disease teaching slide kit. Available at: www.goldcopd.com/slides/download.ppt. $4 $2 $0 COPD Mbidity and Mtality: 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases. NIH/NHLBI. May 2002. 2
Global Strategy f Diagnosis, Management and Prevention of COPD Manage Stable COPD: Non-pharmacologic Current treatment guidelines f COPD focus Ba rriers to providing optimal treatment Patient Group A Essential Recommended Depending on local guidelines Smoking cessation (can include pharmacologic treatment) Physical activity Flu vaccination Pneumococcal vaccination B, C, D Smoking cessation (can include pharmacologic treatment) Pulmonary rehabilitation Physical activity Flu vaccination Pneumococcal vaccination 203 Global Initiative f Chronic Obstructive Lung Disease Current Inhaled Medications f COPD β2-agonists Sht-acting Albuterol ProAir, Proventil, Ventolin 2 puffs q 4-6 hrsprn 4-6 h Levalbuterol Xopenex HFA 2 puffs q 4-6 hrsprn 4-6 h Pirbuterol Maxair Autohaler 2 puffs q 4-6 hrsprn 5 h Long-acting Current Inhaled Medications f COPD Cont d Anticholinergics Sht-acting Ipratropium bromide Atrovent 2 puffs qid 6-8 h Long-acting Aclidinum Tudza Pressair puff bid 24+ h Tiotropium bromide Spiriva Handihaler inhaled capsule daily 24+ h Fmoterol FadilAerolizer, Perfomist, Brovana inhaled capsule bid 2+ h Combination Bronchodilats Indacaterol Arcapta Neohaler inhaled capsule daily 24+ h Salmeterol Serevent Diskus puff bid 2+ h Albuterol/ipratropium Combivent 2 puffs q 4-6 hrsprn 4-6 h Umeclidinum/Vilanterol Ano Ellipta puff daily 24 h HFA = hydrofluoalkane. http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=fbe6d54-9d89-48f7-80a0-db4983f203. Accessed April 3, 204. CazzolaM, et al. Drugs Today. 20;06:84-90. http://www.pdr.net/. Accessed April 3, 204. PL Detail- Document, Inhalers f COPD. Pharmacist s Letter/Prescriber s Letter. August 203. * NEW: Titropium/olodaterol (Stiolto) http://www.pdr.net/. Accessed April 3, 204. Salmon M, et al. J Pharmacol Exp Ther. 203;345(2):260-70. Slack RJ, et al. J Pharmacol Exp Ther. 203;344():28-30. PL Detail-Document, Inhalers f COPD. Pharmacist s Letter/Prescriber s Letter. August 203. Current Inhaled Medications f COPD Cont d Inhaled Cticosteroids Budesonide Pulmict Flexhaler -2 puffs bid 2 h Fluticasone Flovent HFA -2 puffs bid 2 h Beclomethasone QVAR -2 puffs bid 2 h Combination Inhalers Fmoterol/Budesonide Symbict 2 puffs bid 2 h Fluticasone/Salmeterol Advair Diskus Advair HFA puff bid 2 puffs bid Fluticasone/Vilanterol Breo Ellipta puff daily 24 h 2 h Current Oral Medications f COPD Cticosteroids Methylprednisolone Prednisolone Prednisone PDE4 Inhibit 4-48mg/day depending on 5-60mg/day depending on 5-60mg/day depending on 2-24 h 2-24 h 2-24 h Roflumilast Daliresp One 500 mcg tablet daily 7+ h HFA = hydrofluoalkane ; PDE4 = phosphodiesterase 4. PL Detail-Document, Inhalers f COPD. Pharmacist s Letter/Prescriber s Letter. August 203. http://www.pdr.net/. Accessed April 3, 204. Slack RJ, et al. J Pharmacol Exp Ther. 203;344():28-30. HFA = hydrofluoalkane ; PDE4 = phosphodiesterase 4. Using Oral Cticosteroids: a toolbox. Pharmacist s Letter/Prescriber s Letter. 200;26(5):260507. http://www.pdr.net/. Accessed April 3, 204. 3
Percentage Crectly Diagnosed With Obstructive Lung Disease 9/7/207 Global Strategy f Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy (Medications in each box are mentioned in alphabetical der, and therefe not necessarily in der of preference.) Other Management Issues Patient A B Recommended First choice SAMA prn SABA prn LABA Alternative choice LABA SABA and SAMA and LABA Oxygen Rest/exercise/sleep Targets? SpO2>88% crect? Action plan f AECOPD Bronchodilats/antibiotics/steroids/hot line C ICS + LABA and LABA and PDE4-inh. LABA and PDE4-inh. D ICS + LABA and/ ICS + LABA and ICS+LABA and PDE4-inh. and LABA and PDE4-inh. Current treatment guidelines f COPD focus Ba rriers to providing optimal treatment Barriers Clinician barriers Proper diagnosis/staging/prescribing per guidelines Patient barriers Understanding complex medication regimens Adherence to treatment plans (both pharmaceutical and non-pharmaceutical) System barriers Costs of medications Clinical suppt structures Clinical COPD Is Just The Tip Of The Iceberg COPD Often Unrecognized During Hospitalization. 2 Million severe SUBCLINICAL COPD *Repeated exacerbations and hospitalizations Mannino. MMWR Surveill Summ. 2002;5(6):-6. 0 Million Dx? Millions at risk 90 80 70 60 50 40 30 20 0 0 Mild Moderate Severe Very Severe Reproduced with permission. Zaas D et al. Chest. 2004;25:06-. Admission Diagnosis Discharge Diagnosis 4
Adherence to Treatment Plans Pha rmaceutical regimen Maintenance and rescue (AECOPD action plans) Non-pharmaceutical Smoking cessation Vaccinations Exercise Clinical Suppt Structure Access to clinicians Hot lines Home visits Education Discharge planning Medications Follow-up plans Rehabilitation centers Barriers Clinician barriers Proper diagnosis/staging/prescribing per guidelines Patient barriers Understanding complex medication regimens Adherence to treatment plans (both pharmaceutical and non-pharmaceutical) System barriers Costs of medications Clinical suppt structures Current treatment guidelines f COPD focus Barriers to providing optimal treatment 5