Updates 2018 Neil MacIntyre MD Duke University Durham NC. Barnes PJ. N Engl J Med. 2000;343:269-80. 1
COPD spectrum Proximal predominant (large airways) mucus gland hypertrophy (cough/sputum) reduced respiraty drive airway hyper-reactivity Distal predominant (small airways/alveoli) dyspnea - active respiraty drive reduced DLCO COPD spectrum table COPD: the clinical spectrum COPD is a systemic disease Chronic airway inflammation spills inflammaty cytokines into the circulation ASCVD Renal insufficiency Neuro-myopathy Osteoposis Cachexia, debility may be product of this Emphysema Bronchitis Resp Care. 2006; 51: 840-8 COPD natural histy depends on tobacco exposure/sensitivity 2
Proption of 1965 Rate 4/4/2018 COPD Projected to Be the Third-Leading Cause of Death by 2020 COPD: Direct Cost 3.0 2.5 2.0 Proption of 1965-1998 Rate, Percentage Change in Age-Adjusted Death (US) $20 $18 $16 $14 $12 Nursing Home Care* Home Health Care* Physician Services 1.5 $10 Hospital Care 1.0 $8 $6 Prescription Drugs 0.5 0.0-59% -64% -35% +163% -7% Conary Heart Disease Stroke Other CVD COPD All Other 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. EXPOSURE TO RISK FACTORS Diagnosis of COPD AND/ OR SPIROMETRY SYMPTOMS sputum cough dyspnea wheezing Adapted with permission from the GOLD web site. Available at: www.goldcopd.com. Spirometry COPD: the spirogram Nmal Obstructed Restricted 3
Risk (GOLD Classification of Airflow Limitation) Risk (Exacerbation histy) 4/4/2018 Global Obstructive Lung Disease (GOLD) Constium Staging Spirometry can miss emphysema www.goldcopd.com In COPDgene, 357 of 858 smokers with nmal spirometry had emphysema on CT Symptoms/function as imptant as FEV1 on survival BODE: Dyspnea, 6MWT, BMI, FEV1 GOLD 2017: Combined Assessment of COPD Diagnose COPD Spirometry not enough Radiology (hyperinflation, emphysema) and DLCO alternate diagnostic tools Two components determine severity of disease Symptom assessment Risk of exacerbations CAT = COPD assessment test; mmrc = modified Medical Research Council. Global Initiative f Chronic Obstructive Lung Disease. 2014. http://www.goldcopd.g/guidelines-global-strategyf-diagnosis-management.html. Accessed March 6, 2014. Global Strategy f Diagnosis, Management and Prevention of COPD Combined Assessment of COPD 4 3 2 1 (C) (A) mmrc 0-1 CAT < 10 Symptoms (mmrc CAT sce)) (D) (B) mmrc > 2 CAT > 10 > 2 1 0 4
GOLD 2017 1)Diagnose 2) Obstruction Severity 3) Impact GOLD Guidelines 2017 Guided by impact not physiology Global Strategy f Diagnosis, Management and Prevention of COPD Manage Stable COPD: Non-pharmacologic Patient Group Essential Recommended Depending on local guidelines A 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 2013 Global Initiative f Chronic Obstructive Lung Disease Current Inhaled Medications f COPD Medication Brand Usual Starting Dose Duration β 2 -Agonists Sht-acting Albuterol ProAir, Proventil, Ventolin 2 puffs q 4-6 hrs PRN 4-6 h Levalbuterol Xopenex HFA 2 puffs q 4-6 hrs PRN 4-6 h Pirbuterol Maxair Autohaler 2 puffs q 4-6 hrs PRN 5 h Long-acting Fmoterol Fadil Aerolizer, Perfomist, Brovana 1 inhaled capsule bid 12+ h Indacaterol Arcapta Neohaler 1 inhaled capsule daily 24+ h Salmeterol Serevent Diskus 1 puff bid 12+ h HFA = hydrofluoalkane. http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=fbe6d514-9d89-48f7-80a0-d1b41983f203. Accessed April 3, 2014. Cazzola M, et al. Drugs Today. 2011;106:84-90. http://www.pdr.net/. Accessed April 3, 2014. PL Detail- Document, Inhalers f COPD. Pharmacist s Letter/Prescriber s Letter. August 2013. Current Inhaled Medications f COPD Cont d Medication Brand Usual Starting Dose Duration Anticholinergics Sht-acting Ipratropium bromide Atrovent 2 puffs qid 6-8 h Long-acting Aclidinum Tudza Pressair 1 puff bid 24+ h Tiotropium bromide Spiriva Handihaler 1 inhaled capsule daily 24+ h Combination Bronchodilats Albuterol/ipratropium Combivent 2 puffs q 4-6 hrs PRN 4-6 h Umeclidinum/Vilanterol Ano Ellipta 1 puff daily 24 h * NEW: Titropium/olodaterol (Stiolto) http://www.pdr.net/. Accessed April 3, 2014. Salmon M, et al. J Pharmacol Exp Ther. 2013;345(2):260-70. Slack RJ, et al. J Pharmacol Exp Ther. 2013;344(1):218-30. PL Detail-Document, Inhalers f COPD. Pharmacist s Letter/Prescriber s Letter. August 2013. 5
Current Inhaled Medications f COPD Cont d Medication Brand Usual Starting Dose Duration Inhaled Cticosteroids Budesonide Pulmict Flexhaler 1-2 puffs bid 12 h Fluticasone Flovent HFA 1-2 puffs bid 12 h Beclomethasone QVAR 1-2 puffs bid 12 h Combination Inhalers Fmoterol/Budesonide Symbict 2 puffs bid 12 h Fluticasone/Salmeterol Advair Diskus Advair HFA 1 puff bid 2 puffs bid Fluticasone/Vilanterol Breo Ellipta 1 puff daily 24 h HFA = hydrofluoalkane; PDE4 = phosphodiesterase 4. PL Detail-Document, Inhalers f COPD. Pharmacist s Letter/Prescriber s Letter. August 2013. http://www.pdr.net/. Accessed April 3, 2014. Slack RJ, et al. J Pharmacol Exp Ther. 2013;344(1):218-30. 12 h The latest compounds and fmulations - 2017 LABAs Oladaterol SMI (Stiverdi) LAMAs Glycopyronium DPI (Seebri) Umeclidium DPI (Incruse) LABA/ICS Fmoterol/beclamethasone MDI and DPI (Fostair) Fmoterol/mometasone MDI (Dulera) The latest compounds and fmulations - 2018 LAMA/LABA Fmoterol/aclidinium DPI (Genuair) Fmoterol/glycopyrronium MDI* (Bevespi) Indacaterol/glycopyronium DPI (Ultibro) Oladaterol/tiotropium SMI (Stiolto) LAMA/LABA/ICS Stay tuned Trelegy Ellipta Current Oral Medications f COPD Medication Brand Usual Starting Dose Duration Cticosteroids Methylprednisolone Prednisolone Prednisone PDE4 Inhibit 4-48mg/day depending on disease and response 5-60mg/day depending on disease and response 5-60mg/day depending on disease and response 12-24 h 12-24 h 12-24 h Roflumilast Daliresp One 500 mcg tablet daily 17+ h * co-suspension technology HFA = hydrofluoalkane; PDE4 = phosphodiesterase 4. Using Oral Cticosteroids: a toolbox. Pharmacist s Letter/Prescriber s Letter. 2010;26(5):260507. http://www.pdr.net/. Accessed April 3, 2014. 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 C D Recommended First choice SAMA prn SABA prn LAMA LABA ICS + LABA LAMA ICS + LABA and/ LAMA Alternative choice LAMA LABA SABA and SAMA LAMA and LABA LAMA and LABA LAMA and PDE4-inh. LABA and PDE4-inh. ICS + LABA and LAMA ICS+LABA and PDE4-inh. LAMA and LABA LAMA and PDE4-inh. Oxygen Rest/episodic Targets? SpO2>88% crect? Nocturnal NIV f hypercapnia (high pressure) Lancet Resp Med 2014; Sept 2: 298 JAMA 2017;317:2177 Lung volume reduction procedures Surgery vs bronchoscopic Action plan f AECOPD Bronchodilats/antibiotics/steroids/hot line 6
Percentage Crectly Diagnosed With Obstructive Lung Disease 4/4/2018 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;51(6):1-16. 10 Million Dx? Millions at risk 90 80 70 60 50 40 30 20 10 0 Mild Moderate Severe Very Severe Reproduced with permission. Zaas D et al. Chest. 2004;125:106-11. Admission Diagnosis Discharge Diagnosis SPR Perfmance 2006-2012 50.0 Spirometry: HMO PCE Perfmance 2008 2012 90.0 Pharmacotherapy: Cticosteroids (HMO) 45.0 40.0 35.0 30.0 Commercial Medicaid Medicare 85.0 80.0 75.0 Commercial Medicaid Medicare 25.0 70.0 20.0 65.0 15.0 10.0 60.0 5.0 55.0 0.0 50.0 2006 2007 2008 2009 2010 2011 2012 2008 2009 2010 2011 2012 HMO = health maintenance ganization. 7
PCE Perfmance 2008 2012 Barriers Pharmacotherapy: Bronchodilats (HMO) 90.0 85.0 80.0 75.0 70.0 65.0 60.0 55.0 50.0 2008 2009 2010 2011 2012 Commercial Medicaid Medicare 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 LABA Adherence Cost Differences Between Baseline and Followup N = 1014 COPD in health plan given new LABA Prescription filling over 1 year: >80% 26% 60-70% 14% 40-50% 20% 20-30% 21% <20% 19% LAMA/LABA LABA/ICS LAMA/LABA/ICS CHEST 2014, Abstract 12014b Asche CV, et al. Int J Chron Obstruct Pulmon Dis. 2012;7:201-209. Why aren t patients adherent? Lack of understanding of imptance Maintenance vs rescue Ineffective use of devices Breathing maneuvers, device operation Costs The donut hole and drugs running several hundred $/month 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 49 8
System Barriers Access to clinicians Priity scheduling Hot lines Home visits Education Discharge planning Medications Follow-up plans Pulmonary rehabilitation centers Barriers to pulm rehab Less than 2% of COPD patients use PR (COPD 2014; July 1) Why not me? Limited number of programs Cost/reimbursement issues (now CMS reimbursed) Logistics (transpt, timing) Motivation 52 Clinical Suppt Structure Access to clinicians Hot lines Home visits Education Discharge planning Medications Follow-up plans Rehabilitation centers 9