erdosteine in copd_kalbe

8/16/2019 Erdosteine in COPD_Kalbe

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Erdosteine:

its relevancein COPD treatment ?

Luluk Adipratikto


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Global Strategy for Diagnosis, Managemenand Prevention of COPD, 20!: C"a#ters

De$nition and Overvie%

Diagnosis and&ssessment

'"era#e(tic O#tions

Manage Stable COPD

Manage E)acerbations

Manage Comorbidities



'"era#e(tic O#tions

Manage Stable COPD



Updated 2013

© 2013 Global Initiative for Chronic Obstructive Lung Disease


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'"era#e(tic O#tions

Manage Stable COPD





'"era#e(tic O#tions

Manage Stable COPD



Updated 2013



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Global Strategy for Diagnosis, Management and Preventionof COPD

De$nition of COPD COPD, a common #reventable and

treatable disease, is c"aracteri*ed by#ersistent air+o% limitation t"at is(s(ally #rogressive and associated %it"an en"anced c"ronic in+ammatoryres#onse in t"e air%ays and t"e l(ng to

no)io(s #articles or gases

E)acerbations and comorbiditiescontrib(te to t"e overall severity inindivid(al #atients



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Normal Alveolar Emptying


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Alveolar Emptying in COPD

In CO%D' airflo$ is li!ited because alveoli lose their elasticit"'

supportive structures are lost' and s!all air$a"s are narro$ed


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Breathing in COPD


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/is3 actors for COPD

Genes

Infections

Socio-economic

status

Aging Populations© 2013 Global Initiative for Chronic Obstructive Lung Disease


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%#(OG)*)+I+ O, CO%D

TRIGGER FACTOR (i.evirus, smoke, etc)

RESPIRATORY EPITHELIAL

CELL DAAGE

!ACTERIAL PROD"CT(Hist#mi$, %rote#se,etc)

!ACTERIAL

COLO&I'ATIO&(i.e. I$cre#si$ o*#cteri#+ #-esio$)

I&FLAATORY RESPO&S

(r#$u+ositosis#ctiv#tio$)

I&CREASI&G OF OIDATI/ESTRESS (#$tioi#$tco$sumtio$)

DE/ELOP TO COPD


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'"era#e(tic O#tions

Manage Stable COPD





'"era#e(tic O#tions

Manage Stable COPD



U%D#()D 2013



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S!P"O!S

chronic cough

shortness of #reath

E$POS%&E "O &IS'(AC"O&S

to#accooccupation

in)oor*out)oor pollution

SP-/OME'/4: /e5(ired to establis"diagnosis

Global Strategy for Diagnosis, Management and Prevention ofCOPD

Diagnosis of COPD

6

sputum



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S#irometry: ormal 'raceS"o%ing E8 and 8C

1 2 3 - . /

1

2

3

-

V o l u m e , l i t e r s

Time, sec

8C.

1

,)1 -L

,C .L

,)1,C 04



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S#irometry: Obstr(ctiveDisease

V o l u m e , l i t e r s

Time, seconds

.

-

3

2

1

1 2 3 - . /

,)1 14L

,C 32L

,)1,C 0./

*or!al

Obstr(ctive



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&ssessment of COPD

&ssess sym#toms

&ssess degree of air+o%limitation (sing s#irometry

&ssess ris3 of e)acerbations

&ssess comorbidities



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'"e c"aracteristic sym#toms of COPD are c"ronicand #rogressive dys#nea, co(g", and s#(t(m#rod(ction t"at can be variable from day7to7day

Dyspnea: Progressive, #ersistent andc"aracteristically %orse %it" e)ercise

Chronic cough: May be intermittent and may be(n#rod(ctive

Chronic sputum production: COPD #atientscommonly co(g" (# s#(t(m


Sym#toms of COPD



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#ssess s"!pto!s #ssess degree of airflo$ li!itation using

spiro!etr"

#ssess ris5 of e6acerbations

#ssess co!orbidities

Use the CO%D #ssess!ent (est7C#(8or

!9C :reathlessness scale

or

Clinical CO%D ;uestionnaire 7CC;8


&ssessment of COPD



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CA" + COPD Assessment "est


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COPD Assessment Test (CAT): &n


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Clinical COPD "uestionnaire (CC"):Self7administered 5(estionnairedevelo#ed to meas(re clinical control in

#atients %it" COPD ="tt#:99%%%cc5nl>


&ssessment of Sym#toms



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odified 9C 7!9C8;uestionnaire



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#ssess s"!pto!s

#ssess degree of airflo$ li!itation

using spiro!etr" #ssess ris5 of e6acerbations

#ssess co!orbiditiesUse spiro!etr" for grading severit"

according to spiro!etr"' using four

grades split at 40


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Classi$cation of Severity of

&ir+o% .imitation in COPD-n #atients %it" E898C 0;0:

GO.D : Mild E8 @


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#ssess s"!pto!s

#ssess degree of airflo$ li!itation

using spiro!etr" #ssess ris5 of e6acerbations

#ssess co!orbidities Use histor" of e6acerbations and spiro!etr"($o e6acerbations or !ore $ithin the last "ear

or an ,)1 = .0 < of predicted value are

indicators of high ris5


&ssessment of COPD


,COPD


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,COPD

Combined &ssessment ofCOPD

&ssess sym#toms

&ssess degree of air+o% limitation(sing s#irometry

&ssess ris3 of e)acerbations

Comine these assessments or the purpose o impro*ing management o

COPD© 2013 Global Initiative for Chronic Obstructive Lung Disease

,COPD


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,COPD

Combined &ssessment ofCOPD

& i s ,

7 G O L D

C l a s

s i f i c a t i o n o f A i r f l o

-

. i m i t a t i o n 8

& i s ,

7 )

6 a c e r b a t i o n h i s t o r " 8

> 2

1

0

/C0 /D0

/A0 /B0!9C 0?1

C#( = 10

-

3

2

1

!9C > 2

C#( > 10

Symptoms7!9C or C#( score88

Patient is no% in one of fo(r categories:

&: .es sym#toms, lo%ris3

: More sym#toms, lo%

ris3

C: .ess sym#toms, "ig"ris3

D: More sym#toms, "ig"ris3

Use co!bined assess!ent


and Prevention of COPD


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Patient Characteristic SpirometricClassification

E1acer#ationsper year

m!&C CA"

#Lo$ 9is5

Less +"!pto!sGOLD 1?2 @ 1 0?1 = 10

:Lo$ 9is5

ore +"!pto!s GOLD 1?2 @ 1 > 2 A 10

CBigh 9is5

Less +"!pto!sGOLD 3?- > 2 0?1 = 10

DBigh 9is5

ore +"!pto!sGOLD 3?- > 2 > 2

A 10

and Prevention of COPD

Combined&ssessment of

COPDWhen assessing risk, choose the highest risk

according to GOLD grade or exacerbation

history. One or more hospitalizations for COPD

exacerbations shold be considered high risk.!


,f CO


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,of COPD

&ssess COPD

ComorbiditiesCOPD #atients are at increased ris3 for: Cardiovasc(lar diseases Osteo#orosis /es#iratory infections &n)iety and De#ression Diabetes

.(ng cancer"hese comorbid conditions may inflence

mortality and hospitalizations and shold be

looked for rotinely, and treated appropriately .© 2013 Global Initiative for Chronic Obstructive Lung Disease

Global Strategy for Diagnosis Management and Prevention of


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Dierential Diagnosis:

COPD and &st"maCOPD

• Onset in mid7life

• Sym#toms slo%ly#rogressive

• .ong smo3ing "istory

&S'FM&

• Onset early in life =often

c"ild"ood>• Sym#toms vary from day to

day

• Sym#toms %orse at

nig"t9early morning

• &llergy, r"initis, and9orec*ema also #resent

•

amily "istory of ast"ma© 2013 Global Initiative for Chronic Obstructive Lung Disease


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&dditional -nvestigations

Chest +$ray: Seldom diagnostic b(t val(able toe)cl(de alternative diagnoses and establis" #resenceof signi$cant comorbidities

ung Volumes and Di-using Capacity: Fel# toc"aracteri*e severity, b(t not essential to #atientmanagement

O.imetry and Arterial Blood /ases: P(lse o)imetry can

be (sed to eval(ate a #atientHs o)ygen sat(ration andneed for s(##lemental o)ygen t"era#y

Alpha$' Antitrypsin Deciency 0creening: Perform%"en COPD develo#s in #atients of Ca(casian descent

(nder B years or %it" a strong family "istory of© 2013 Global Initiative for Chronic Obstructive Lung Disease

Global Strategy for Diagnosis Managemen


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Global Strategy for Diagnosis, Managemenand Prevention of COPD, 20!: MaIorC"a#ters



'"era#e(tic O#tions

Manage Stable COPD




Diagnosis and

&ssessment

'"era#e(tic O#tions

Manage Stable COPD



U%D#()D 2013


Global Strategy for Diagnosis, Management and Prevention of


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-denti$cation and red(ction of e)#os(re to ris3factors are im#ortant ste#s in #revention andtreatment

-ndivid(ali*ed assessment of sym#toms, air+o%limitation, and f(t(re ris3 of e)acerbationss"o(ld be incor#orated into t"e managementstrategy

&ll COPD #atients bene$t from re"abilitationand maintenance of #"ysical activity

P"armacologic t"era#y is (sed to red(cesym#toms, red(ce fre5(ency and severity ofe)acerbations, and im#rove "ealt" stat(s and

gy g , g

COPD

Manage Stable COPD: Jey Points




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.ong7acting form(lations of beta07agonists and antic"olinergics are#referred over s"ort7acting

form(lations ased on eKcacy andside eects, in"aled bronc"odilatorsare #referred over oral bronc"odilators

.ong7term treatment %it" in"aledcorticosteroids added to long7actingbronc"odilators is recommended for

#atients %it" "ig" ris3 of

gy g g

COPD





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.ong7term monot"era#y %it" oral orin"aled corticosteroids is notrecommended in COPD

'"e #"os#odiesterase7 in"ibitorro+(milast may be (sef(l to red(cee)acerbations for #atients %it" E8

B0A of #redicted, c"ronic bronc"itis,and fre5(ent e)acerbations

gy g g

COPD



COPD


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9elieve s"!pto!s

I!prove e6ercise tolerance

I!prove health status

%revent disease progression

%revent and treat e6acerbations

9educe !ortalit"

9educe

s"!pto!s

9educeris5

Manage Stable COPD: Goals of

'"era#y



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&voidance of ris3 factors

7 smo3ing cessation

7 red(ction of indoor #oll(tion

7 red(ction of occ(#ationale)#os(re

-n+(en*a vaccination

Global Strategy for Diagnosis, Management and Prevention of COPD

Manage Stable COPD: &ll COPD Patients



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Manage Stable COPD: on7#"armacologic

PatientGroup

Essential &ecommen)e) Depen)ing on localgui)elines

#+!o5ing cessation 7caninclude phar!acologic

treat!ent8%h"sical activit"

,lu vaccination%neu!ococcal

vaccination

:' C' D

+!o5ing cessation 7caninclude phar!acologic

treat!ent8%ul!onar" rehabilitation

%h"sical activit",lu vaccination%neu!ococcal

vaccination


Global Strategy for Diagnosis Management and Prevention of COPD


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Manage Stable COPD: P"armacologic '"era#y( Medications in each box are mentioned in alphabetical order, and

therefore not necessarily in order of preference.)

Patient &ecommen)e)(irst choice

Alternative choice Other Possi#le"reatments

#+## prn

or +#:# prn

L##or

L#:#or

+#:# and +##

(heoph"lline

:L##

or L#:#

L## and L#:#+#:# and#or +##

(heoph"lline

C

IC+ L#:#or

L##

L## and L#:# or L## and %D)-?inh. or L#:# and %D)-?inh

+#:# and#or +##(heoph"lline

D

IC+ L#:#and#or L##

IC+ L#:# and L## or IC+L#:# and %D)-?inh or

L## and L#:# or L## and %D)-?inh.

C arboc"steine$%&% and or +##

(heoph"lline



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> 2

1

0

!9C 0?1

C#( = 10

GOLD -

!9C > 2

C#( > 10

GOLD 3

GOLD 2

GOLD 1 Theophylline

0ABA and1or 0AMA

Theophylline

Carocysteine

0ABA and1or 0AMA

Theophylline

0ABA and1or 0AMA

Theophylline

Manage Stable COPD: P"armacologic '"era#y

O'FE/ POSS-.E '/E&'ME'S

&

DC

) 6 a

c e r b a t i o n s p

e r " e a r



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Er)osteine+ its relevance in COPD

treatment 2

+tandart treat!ent erdostein 300!g :ID E?

10da"s

In clinicall" stable CO%D' long?ter! treat!ent isassociated $ith a reduction in acute e6acerbation

and hospitaliFation rate and a significant

i!prove!ent of ualit" of life )rdosteine could

be !ost beneficial in patients $ho haverepeated' prolonged or severe e6acerbations of

CO%D oretti )6pert Opin Drug etab (o6icol 200H ar.738333?-3 doi101.1E1E-2.2.0H0241-EH0

http://www.ncbi.nlm.nih.gov/pubmed?term=Moretti%20M%5BAuthor%5D&cauthor=true&cauthor_uid=19331595http://www.ncbi.nlm.nih.gov/pubmed/19331595http://www.ncbi.nlm.nih.gov/pubmed/19331595http://www.ncbi.nlm.nih.gov/pubmed?term=Moretti%20M%5BAuthor%5D&cauthor=true&cauthor_uid=19331595http://www.ncbi.nlm.nih.gov/pubmed/19331595http://www.ncbi.nlm.nih.gov/pubmed?term=Moretti%20M%5BAuthor%5D&cauthor=true&cauthor_uid=19331595


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(he therapeutic efficac" of erdosteine in the treat!ent of chronicobstructive bronchitis a !eta?anal"sis of individual patient

data'Cazzola (, )loriani *, Page CP!

(reat!ent $ith erdosteine $as associated

$ith significant a!elioration of s"!pto!sin co!parison to placebo or treat!ent $ith

!ucol"tics in patients $ith chronic

obstructive bronchitis


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Erdosteine dapat membantu mencegah progresi penyakit karenabekerja dari beberapa faktor penting patogenesis dari bronkitis kronik

Cole J Kilson icious Circle B"pothesisM"empat er)osteine #e,er3a

Erdosteine pada PPOK

I%#I9)D UCOCILI#9N

CL)#9#*C)

:#C()9I#L %9ODUC(+

7hista!ine' proteases' etc8

D##G) (O #I9K#N

)%I(B)LIU

:#C()9I#L COLO*I+#(IO*

7eg' increased bacterial adhesion8

%9OG9)++ to CO%D

I*C9)#+)D OID#(I) +(9)++

7consu!ption of antio6idants8

I*,L##(O9N 9)+%O*+)

7attractionactivation of granuloc"tes8


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/Er)osteine0

VESTE IN

"4AN' O%

erdosteine in copd_kalbe

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