Download - COPD: Reversing the Reversible in 2014
COPD: Reversing the Reversible in
2014Donald M. Pell M. D., FCCP
Introduction Prevalence 5.9% of U.S. population
or about 24,000,000 adults (ATS Gold Paper 2004)
In 2000 there were 122,000 deaths (CDC data)
For the first time more women than men
2nd to heart disease as a cause of disability
Annual cost 2002 est. $32.1 billion 70% of the patients were less than
65
Introduction By 2005, there were 126,000 deaths
and the number of male deaths had increased by 8%.
The number of female deaths had increased by 11% (CDC data)
Spectrum of COPD
COPD80%PURE EMPHYSEMA
10%
CHRONIC BRONCHITIS
10%
REVERSIBLE COMPONENTS of COPD SPUTUM SPASM SWELLING
Differentiating COPD and Asthma
No diagnostic test for either is conclusive
Frequent coexistence of both problems
10% overlap
Autonomic Effects on Respiratory Tract
DMP-2000
Short Acting Beta 2 Agonist
BRONCHODILATORMedication Dose
DurationIsuprel Isoproterenol 130mcg/p 2pq3-4h
.5-2hBronkosol Isoetharine 3-40mcg/p 2pq4h
2-4hAlupent Metaproterenol 65mcg/p 2pq4-
6h 4-6hBrethine Terbutaline 200mcg/p 2pq4-6h
4-6hProventil Albuterol 90mcg/p 2pq4-6h
4-6hMaxair Pirbuterol 200mcg/p 2pq4-
6h 4-6hTornolate Bitolterol 370mcg/p 2pq4-6h
5-8h
Lancet, Feb 2003
Long Acting Beta 2 Agonist
BRONCHODILATORMedication Dose
DurationSerevent Diskus Inhale 1 BID
12hForadil (Fomoterol) Inhale 1 BID
12hAdvair 50/500 Inhale 1 BID
12hSymbicort160/4.5 Inhale 2 BID
12h
Theophylline Mechanisms of effects Improved efficiency of the
diaphragm Anti-inflammatory Bronchodilator Respiratory center stimulant Narrow therapeutic window Frequent drug interactions
FEV1 and Aging Healthy lungs lose about 20 cc@
year after age 25 COPD patients lose about 80 cc@
year
Summary of New Therapies
Non pharmaceutical supplements (Boswellia)
Supplemental Oxygen (Oximizer) COPD rehab Leukotriene modifiers Cilomilast Tioproprium Bromide Foradil Statins ACE Inhibitors
Leukotriene Modifiers and COPD
Reports at international and national meetings
Proposed mechanism Local experience 18 patients with
severe COPD 2 week trial LM Average response to SABA before
trial 9% After trial 40%
StatinsVast improvement in
lung transplant survival91% vs 54%
Johnson Am J Crit Care Med (167), 1271-1278 2003
StatinsMarked reduction in
number of exacerbationsby 2/3
ACE InhibitorsAdditional improvements
when added to statins
Proposed Pathophysiology
Barnes, NEJM, 2000
Barnes, NEJM, 2000
Barnes, NEJM, 2000
Mancini, JACC, vol 27, 2006
Effects of statins on COPD and Influenza
mortality 150,000 patients, 90 days of statins
minimum Low dose group <4 mg/day Moderate dose group >4 mg/day Usual dose 10 mg/day 2 year USA HMO study
Floyd& Foster, Chest (131), 1006-1012
Effects of statins on COPD and Influenza
mortality Deaths by disease category Low Moderate No
StatinPneumonia 11 18 94COPD 8 5 84Influenza 8 16 80All statin users RR.23 for COPDNo COPD, moderate dose RR .54
Floyd & Foster, Chest (131), 1006-1012
Effects of statins Hospitalized patient deaths due to
influenza/pneumonia Pneumonia All statins 73, Low dose 89, High dose
49 COPDAll statins 29, Low dose 58, High dose
17
Floyd & Foster, Chest (131), 1006-1012
Protection from loss of lung function in COPD
Decrease in FEV1 85 cc/ year in COPD
Decrease in FEV1 5 cc/ year in statin group with or without smoking cessation
Keddissi, Chest (132) 1764-1771
Effect of statin on COPD Mortality
Norwegian study 854 patients mean age 70.8 Follow up 1.9 years 51.5% females
Soyseth European Resp J (29) 279-283 2007
Effects of statin on COPD Mortality
333 died all with severe COPD Statin group 110 died Non-statin group 191 died Hazard reduction statin vs nonstatin
57% Statins alone 69% Statins plus ICS 39%
Soyseth European Resp J (29) 279-283 2007
Effect of statins on COPD deaths
Japanese study All cause mortality results 65 years
and older COPD deaths 152/100,000 in non statin group 8/100,000 in statin group
Tohoku Experimental Med (212) 265-273 2007
Effects of statins Canadian study All patients over 65 High risk had been revascularized Low risk had no MI in prior 5 years
and no NSAIDs Must have had 3 Rx in prior year for
statin & 1 Rx in prior 60 days
Mancini J Amer Col of Cardiology (47) 12 2006
Effects of statins COPD hospitalizations decreased 12-
21% in both groups Death from COPD decreased 38%
with satins Death or MI decreased 47% in high
risk group
Mancini J Amer Col of Cardiology (47) 12 2006
Effects of statins VA study from1998-2004 483,733 patients 33% on statins 7,280 Lung cancer Risk of lung cancer decreased 55%
in statin group RR .45
Khurana Chest (131) 1282-1288 2007
Decreased Exacerbations and Intubations in patients on statins
New Jersey community hospital 185 COPD pts
90 on statins 95 not on statins Average age 70, Duration 1 year Average FEV1 38% predicted Exacerbations reduced 90% in statin
group Intubations reduced 90% in statin
groupBlamoun International J Clin Pract (62)
1373-78 2008
Safety of statins Study from 1985-2006 1/10,000 risk of myopathy Risk increases with fibrates Other drug interactions Hypothyroid Decreased GFR Over age 80
Lancet June 2007
SUMMARY Sputum, Spasm and Swelling all
have some degree of reversibility and that becomes the basis for treating COPD.
New treatments are being studied and have been reported in Europe, Canada and the US.
Pell’s Pearl More than 90% of all patients with COPD have some degree of reversibility.