Blue, Pink and everything in between: an update on COPD Tara Lohmann MD FRCPC Division of Respirology University of Calgary
Disclosures I have eaten lunches provided by many pharmaceutical companies (GSK, Boeringer-Ingleheim, AstraZeneca, Novartis)
Outline 1. Highlights of the 2017 COPD statements - What s with inhaled corticosteroids in COPD? - Inhaler review 2. Update on smoking cessation 3. INSPIRED TM to reduce hospitalizations in COPD
John 71 year old retired carpenter Presents to your clinic with slowly progressive dyspnea mmrc4 Known COPD (FEV 1 47%). 3 Hospitalizations for AECOPD in the past year Smokes 1 ppd (60 pack-year Hx) COPD Meds: Tiotropium 18ug daily (LAMA) Salbutamol prn (SABA)
NEJM 2014: 371; 4
What patient category is John in? a. A b. B c. C d. D e. Huh?
Vogelmeier et al. AJRCCM 2017
Vogelmeier et al. AJRCCM 2017
COPD Assessment Test (CAT) www.catestonline.org
Gruffydd-Jones K Prim Care Respir J 2012; 21:437-441
What will you do with his inhalers? a) Add LABA (dual bronchodilator therapy) b) Add LABA/ICS combination (triple therapy) c) Tell him the inhalers won t help him; he can stop them d) Add ipratropium (SAMA) prn e) No change
Bourbeau et al. Canadian Journal sleep, critical care, sleep medicine 2017
When do you add inhaled corticosteroids (ICS)? a) Not needed for this patient: He doesn t have asthma b) If he continues to exacerbate despite LAMA/LABA c) When the IM resident tells you to d) Always. More is better in COPD
Risks of Inhaled Corticosteroids (ICS) Pneumonia (OR 2.0) Elderly BMI >25 More severe airflow obstruction Non-tuberculous mycobacteria (OR 2.51) Osteoporosis Cataracts Glaucoma Ernst et al. ERJ 2015; 45: 525-537 Yiu et al. Annals ATS 2018
Magnussen et al. NEJM 2014
Is triple therapy more effective at reducing exacerbations than dual therapy? Lipson et al. NEJM 2018; 378 (18)
IMPACT trial results Lipson et al. NEJM 2018; 378 (18)
Bottom line for ICS in COPD ICS should NOT be used as monotherapy in COPD Consider ICS in addition to LAMA/LABA for those with moderatesevere COPD and frequent exacerbations ICS may benefit those with peripheral eosinophilia (2-4% or >=300 cell/ul) OR sputum eosinophilia (>3%) OR an Asthma-COPD phenotype Withdrawal of ICS in COPD is likely safe Bourbeau et al. Canadian Journal sleep, critical care, sleep medicine 2017
Inhaler update
What s new in Smoking cessation Very brief intervention (A s) Nicotine replacement plus varenicline E-cigarettes Smartphone technology Hartmann-Boyce et al. Cochrane Database of Systematic reviews 2016
What you do matters! Inpatients 19% of inpts who had a smoking cessation intervention had remained abstinent 6 months post discharge (BMJ 2013) Pre-operative clinic Smoking quit rates pre-operatively are higher than for patients who quit for general health reasons (Thorac Surg Clin 2012) Recent data suggests quitting within 2-4 weeks of surgery doesn't have worse outcomes (Systematic review J anesth 2013)
AAR: If time is of the essence
JAMA. 2014;312(2):155-161. doi:10.1001/jama.2014.7195
JAMA. 2014;312(2):155-161. doi:10.1001/jama.2014.7195
E-cigarettes: Jury is still out E-cigarettes with nicotine likely more effective than E-cig alone Fewer toxicants than cigarettes (Tob Con 2014) Still no proof of longterm safety May alter gene expresstion (Clin Cancer Res 2014) May be toxic to alveolar macrophages (Thorax 2018) Nicotine in E-cigarettes soon to be legal in Canada McRobbie et al. Cochrane syst rev 2014; 12 Middlekauf Chest 2015
Smoking Cessation Apps
How to reduce John s readmissions? Pulmonary rehabilitation (< 4 weeks of AECOPD) (1C) Written action plan + case management (2B) - INSPIRED Pharmacologic therapies Criner et al. CHEST 2015
INSPIRED COPD Outreach Program TM Rocker, G.M. & Verma, J. INSPIRED COPD Outreach Program : Doing the right things right. Clinical & Investigative Medicine 2014; 38(1): E311-E319.
http://www.copdactionplan.com/cts_copd_updated_action_plan_editable_pdf_2013.pdf
Outline 1. Highlights of the 2017 COPD guidelines - What s with inhaled corticosteroids in COPD? - Inhaler review 2. Update on smoking cessation 3. INSPIRED TM and other ways to reduce hospitalizations in COPD
Thank you!
Resources https://www.albertaquits.ca/ https://www.canada.ca/en/health-canada/services/canadian-tobaccoalcohol-drugs-survey.html https://www.livingwellwithcopd.com/3-39-user-tool-how-to-use-myinhaler-properly-.html www.resptrec.org