outlineofpresentaon* asthma vs. copd
TRANSCRIPT
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Current Strategies for Asthma and COPD
Talmadge E. King, Jr., M.D. Julius R. Krevans Distinguished Professorship in Internal Medicine
Chair, Department of Medicine University of California San Francisco (UCSF)
San Francisco, CA
Disclosure Statement
Dr. King has served on a Scien2fic Advisory Board for the following companies: • InterMune • ImmuneWorks • Boehringer Ingelheim • Daiichi Sankyo Pharma • UpToDate
Outline of Presenta3on • Asthma
– Burden of disease – Diagnosis – Management
• COPD – Burden of disease – Diagnosis – Smoking cessa2on – Approach to Management
ASTHMA vs. COPD
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Asthma 5
ASTHMA: Take Home Messages 1. Asthma is chronic inFlammatory disease of the airways; leads to hyperresponsiveness to stimuli that causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning.
2. Clinical manifestations of asthma can be controlled with appropriate treatment – there should be no more than occasional Flare-‐ups and severe exacerbations should be rare.
3. Measurement of lung function (spirometry or peak expiratory Flow) provide an assessment of the severity of airFlow limitation, its reversibility, and its variability, and provide conFirmation of the diagnosis of asthma.
ASTHMA: Take Home Messages
4. Medications to treat asthma can be classiFied as controllers or relievers. – Controllers = medications taken daily on a long-‐term basis to
keep asthma under clinical control chieFly through their anti-‐inFlammatory effects.
– Relievers = medications used on an as-‐needed basis that act quickly to reverse bronchoconstriction and relieve its symptoms.
5. Inhaled glucorticosteroids are the most effective controller medications.
ASTHMA: Take Home Messages 6. Rapid-‐acting inhaled beta2-‐agonist are the medications of
choice for relief of bronchoconstriction and pretreatment of exercise-‐induced bronchoconstriction.
7. Clinical control of asthma is deFined as: – NO (twice or less/week) daytime symptoms – NO limitations of daily activities, including exercise – NO nocturnal symptoms or awakening because of asthma – NO (twice or less/week) need for reliever treatment – Normal or near-‐normal lung function – NO exacerbations
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ASTHMA
• A chronic inBlammatory disease of the airways; • Chronic inBlammation leads to hyperresponsiveness to stimuli;
• Variable and reversible airBlow obstruction.
Asthma • A common chronic disease worldwide
– ~ 300 million persons are affected worldwide.
– ~14.9 million persons in the US – Dramatic increases in the prevalence of atopy and asthma in Westernized countries and more recently in less-‐developed nations.
– Responsible for about • 500,000 hospitalizations, • 5,000 deaths, and • 134 million days of restricted activity a year.
Asthma
• Optimal management of asthma (we are better!)
– improves quality of life – decreases the pool of those at risk for death
– saves healthcare costs in emergency care
Diagnosis of Asthma: 3 Steps
1. Obtain a history of episodic symptoms of airFlow obstruction
2. Demonstrate that airBlow obstruction is at least partially reversible
3. Exclude alternative diagnoses
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Alternative Diagnoses • COPD • Vocal cord dysfunction • CHF • Pulmonary embolism • Drug-‐induced cough • Pulmonary inFiltration with eosinophilia • Obstructive sleep apnea • Mechanical obstruction
– e.g. benign or malignant tumor
Clues to Diagnosis • Recurrent episodes of wheezing • Troublesome cough at night • Cough or wheeze after exercise • Cough, wheeze or chest tightness after exposure to airborne dust, allergens • Colds that “go to the chest” or take more than 10 days to clear
Spirometry Establishes the Diagnosis
• By demonstrating obstruction: – FEV1 < 80% predicted – FEV1/FVC < 65% predicted or below the lower limit of normal
• By demonstrating reversibility: – FEV1 increases >12% and at least 200 mL
Measurement of Peak Flow • When spirometry is normal but patients still have symptoms, follow up with peak Flow monitoring for 1-‐2 weeks upon arising and in the afternoon (before and after inhaled bronchodilator).
• Difference of 20% between high and low readings on same day suggests asthma.
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Asthma Guidelines 4 Essential Components
1. Assessment & monitoring 2. Patient education 3. Control of factors contributing to asthma severity
4. Pharmacologic treatment National Asthma Education and Prevention Program: Expert panel Report 3
• Stepwise approach expanded to 6 steps with repositioned medications
• Emphasis on patient education/partnership – education at all points of care
• More attention to control of environmental factors or comorbid conditions – multifaceted approaches – consideration of SQ immunotherapy in persistent asthma
– beneFit from treating comorbid conditions
Asthma Guidelines
Assessment &
Monitoring
Asthma Care: 4 Essential
Components
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Assessment & Monitoring • Assess asthma severity to initiate Rx (based on current impairment)
• Assess asthma control to monitor and adjust Rx (based on the risk of future negative events)
• Stepwise approach – Schedule follow-‐up care – Assess control – Medication technique – Written action plan – Adherence at each visit
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Severity vs. Control • SEVERITY = intrinsic intensity of the disease process
– Emphasized for initiating therapy • CONTROL = degree of success of treatment – Emphasized for monitoring and adjusting therapy
Eur Respir J. 2008 Sep;32:545-54
Assessment of Impairment • Key elements of impairment:
– Patient’s recall of symptoms – Nighttime awakenings – Physical activity (esp. interference with normal activity)
– Need for rescue medications in the preceding 2 to 4 weeks (Short-‐acting beta2 agonist use)
– Frequency and severity of exacerbations – Quality of life – Current pulmonary function
Assessment of Impairment
• Patient-centric, validated tools to evaluate the current asthma control include:
– Asthma Therapy Assessment Questionnaire (ATAQ)
– Asthma Control Questionnaire (ACQ)
– Asthma Control Test (ACT)
Aidan A. Long, MD: www.peerviewpress.com/d/p131
Determine Severity When Initiating Therapy
Components of Severity
INTERMITTENT PERSISTENT
Mild Moderate Severe
Symptoms <2 days/week >2 days/week Daily All day
Nighttime awakenings <2 days/month 3-4 x/month >1/week Up to 7x/ week
Short-acting beta2 agonist use
<2 days/week >2 days/week Daily Several times a day
Interference with normal activity None Minor Some Extreme
Lung Function FEV1 normal FEV1 > 80% FEV1 60-80% FEV1<60%
<2
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Determine Severity When Initiating Therapy
Components of Severity
INTERMITTENT PERSISTENT
Mild Moderate Severe
Symptoms <2 days/week >2 days/week Daily All day
Nighttime awakenings <2 days/month 3-4 x/month >1/week Up to 7x/ week
Short-acting beta2 agonist use
<2 days/week >2 days/week Daily Several times a day
Interference with normal activity None Minor Some Extreme
Lung Function FEV1 normal FEV1 > 80% FEV1 60-80% FEV1<60%
Assessment of Risk
Aidan A. Long, MD: www.peerviewpress.com/d/p131
ClassiBication of Asthma Severity: Based on Risk
Exacerbations requiring use of oral steroids
Intermittent Persistent
Mild Moderate Severe
0-1/yr
>2/yr Less severe,
Longer interval
>2/yr
>2/yr More severe, shorter interval
Initial Treatment: Based on
ClassiBication of Severity
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6 Steps of Asthma Management
Step
1
6 Steps of Asthma Management
Aidan A. Long, MD: www.peerviewpress.com/d/p131
Persistent Asthma
Step
2
6 Steps of Asthma Management
Aidan A. Long, MD: www.peerviewpress.com/d/p131
Persistent Asthma
Step
3
Long-acting beta agonists (LABAs)
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• Patient should only use a LABA at the same time as an inhaled steroid medicine.
• Medicines that have a LABA and steroid in 1 inhaler include • Fluticasone with salmeterol (Advair®) • Budesonide with formoterol (Symbicort®)
• Some LABAs come in a separate inhaler, but you must take them at the same time as a steroid medicine. • Salmeterol (Serevent® Diskus®) • Formoterol (Foradil® Aerolizer®).
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6 Steps of Asthma Management
Aidan A. Long, MD: www.peerviewpress.com/d/p131
Persistent Asthma
Step
4
6 Steps of Asthma Management
Aidan A. Long, MD: www.peerviewpress.com/d/p131
Persistent Asthma
Step
5
6 Steps of Asthma Management
Persistent Asthma
Step
6
6 Steps of Asthma Management
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Steps in ICS Dosages Low Medium High
Vanceril
84 mcg/puff 2-6 puffs 6-10 puffs > 10 puffs
Budesonide (Pulmicort ®)
200 mcg/ inhalation 1-2 inhalations 2-3 >3
Fluticasone (Flovent®)
110 mcg/puff 2 puffs 2-6 puffs > 6 puffs
Aerobid
250 mcg/puff 2-4 puffs 4-8 puffs > 8 puffs
Mometasone (Asmanex Twisthaler®)
200 mcg/inhalation
1 inhalation 2 3
Ciclesonide (Alvesco®)
Once treatment is established, the emphasis is on assessing asthma control to determine if the goals for therapy have
been met and if adjustments in therapy (step up or step down)
would be appropriate.
After Initial ClassiBication of Severity, Determine Level of Control
Control Very Poorly controlled
Not well controlled
Well Controlled
Symptoms <2 days/wk >2 days/wk All day
Nighttime
Awakenings <2/mo 1-3x/wk >4/wk
Interference with normal activity None Some Extreme
SABA use <2 days/wk >2 days/wk Several/day
FEV1 or peak Blow >80% best 60-80% best <60% best
ACT questionnaire >20 16-19 <15
The Asthma Control Test
SOB
Interference with daily activities
Nighttime awakening
SABA inhaler use
Overall rating
5
5
5
5
5
25
Worse Better
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Adjust Treatment based on Control
Control Very Poorly controlled
Not well controlled
Well Controlled
Step
Maintain,
Consider step down if well for at least 3 months
Step up by 1 step Step up by 1-2 steps
Oral steroids?
No No Consider short course
Follow up Regular,
Q 1-6 mos
Reevaluate
In 2- 6 wks
Reevaluate
In 2 weeks
Before Step-up of Therapy
• Review adherence • Inhaler technique • Environmental control • Co-‐morbid conditions
Patient Education
Asthma Care: 4 Essential
Components
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Patient Education/Partnership
• Self-management education – Teach and reinforce self-‐monitoring • signs of worsening (symptoms or peak Flow) • difference between long-‐term control and quick relief medications • correct inhaler technique • avoiding environmental triggers
– A written asthma action plan
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Peak Flow Meters • Establish patient’s personal best value and evaluate the response to changes in therapy.
• Patients with moderate persistent and severe persistent asthma may beneBit from having a peak Blow meter at home and measuring their level upon arising each morning.
PEF values (personal
best, 80%, 50%)
Controller and
quick-relief medicine plan
Normal Peak Flow Varies by Gender, Age, Ethnicity
Peak Flow Meters: Caveats • Extremely wide variability even in the published predicted peak expiratory Flow reference values
• Effort dependent • Poor at detecting mild obstruction • Reference values differ for each brand of meter – normative brand-‐speciFic values currently are not available for most brands
• Helps in monitoring but not diagnosis – Particularly useful for patients without good ability to sense symptoms
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Inhaler Technique
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Inhaler Technique
50
Dry Powder Inhalers Environmental
Factors &
Comorbid Conditions
Asthma Care: 4 Essential
Components
3
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Environmental factors and comorbid conditions
• Review exposures – advise on ways to reduce exposure – In patients with persistent asthma, consider skin allergy testing and immunotherapy
• Comorbid conditions – ABPA, GE reFlux, obesity, OSA, rhinitis & sinusitis, stress, depression, tobacco abuse
Medications
Asthma Care: 4 Essential
Components
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Medications • Long-term control medications – Inhaled Corticosteroids (ICS) – Long acting beta agonists (LABA) – salmeterol/formoterol – last > 12 h • NOT for monotherapy / to be used with ICS (Step 3-‐4)
– Cromolyn sodium/nedocromil • Step 2 (Mild persistent) • Preventive Rx before exercise or exposure to allergens
– Immunomodulators – omalizumab (anti-‐IgE) • Adjunctive Rx if allergies and Step 5-‐6 care (Severe persistent) • Administered where equipped to treat anaphylaxis
Steroid Treatment Tips • Inhaled corticosteroids should be used for all persistent asthma • ICS must be used with LABA (salmeterol) – due to higher than expected death rates with LABA alone
• Five day course of oral corticosteroids does not require taper • Smokers may require higher ICS doses
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Summary • Stepwise assessment used for initial therapy and adjustment of therapy
• LABA has no role alone – only if used together with ICS
• ICS with all persistent asthma • Patients to be partners in care – asthma control test for monitoring – written asthma action plan for assessment/Rx
Smokers are Different
• Up to 1/3 of asthmatics smoke • 44 non-smokers and 39 light smokers with mild asthma assigned to ICS 2x day or LTA 1x day
– Even with similar FEV1, smokers had worse quality of life, more symptoms
– ICS reduced sputum eosinophils in both – ICS improved FEV1 only in non-‐smokers – LTA improved AM peak Flow only in smokers
Lazarus et al. Am J Respir Crit Care Med. 2007;175:783-90
COPD 59
COPD: Take Home Messages 1. COPD is a common condition with a high mortality. 2. Smoking is most common risk factor. However, in many
countries, outdoor, occupational, and indoor air pollution (burning of biomass fuels) are risk factors.
3. Clinical diagnosis considered in any patient who has dyspnea, chronic cough or sputum production, and risk factors.
4. Spirometry is required to make diagnosis. 5. Appropriate pharmacologic therapy can reduce COPD
symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance.
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COPD: Take Home Messages 6. For symptomatic patients with COPD, pulmonary rehabilitation and
maintenance of physical activity is useful to improve symptoms, exercise capacity, and quality of life.
7. Exacerbation of COPD is an acute event characterized by worsening of respiratory symptoms that are beyond normal day-‐to-‐day variations and leads to a change in medication.
8. Long-‐term oxygen therapy for all patients with COPD who have chronic hypoxemia.
9. All patients should be advised to quit smoking, educated about COPD, and given a yearly inFluenza vaccination.
10. In addition, the pneumococcal polysaccharide vaccine should be given to all patients with COPD.
COPD • A preventable and treatable disease state characterized by airFlow limitation that is not fully reversible. • AirFlow limitation – usually progressive and – associated with an abnormal inFlammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.
Celli B. R. Chest 2008;133:1451-1462
COPD • Cough or wheeze • Sputum production • Dyspnea • Chest tightness • Worsening quality of life (often without clear recognition)
Celli B. R. Chest 2008;133:1451-1462
COPD • Highly prevalent (7 to 19%; M>W; white > blacks; increases with age) • Underdiagnosed (~12M), • Undertreated, • Underperceived, and • Very costly care (~$49.9B in 2010)
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An Accelerated Decline In Lung Function Is The Single Most Important Feature Of COPD
3rd-ranked cause of death in
the US (~100,000 each
year).
COPD: Cigarette smoking
• Most important risk factor. • Smoking leads to – an inFlammatory response, – oxidative stress, – lung destruction, and – interference with lung repair Smokers
Smoker, Severe COPD
Immunostaining with monoclonal antibody anti-CD45
Leukocyte Infiltration in COPD
Smoker, Mild COPD
COPD: Smoking cessation
• Slows the accelerated decline in COPD-‐related FEV1 • Reduces all-‐cause mortality rates by 27% (by reduction in CV mortality)
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COPD • The mortality rate from COPD for women has doubled over the past 20 yrs. • Some studies suggest that women are more susceptible to the effects of tobacco smoke than men
COPD: A persistent Systemic InBlammatory state
Consultant360 12/2011
COPD: A persistent Systemic InBlammatory state
• Associated with important systemic manifestations, especially in patients with more advanced disease. Imbalanced oxidative stress or abnormal immunologic response – decreased fat-‐free mass – impaired systemic muscle function – anemia – osteoporosis – depression – pulmonary hypertension, and cor pulmonale – all of which are important determinants of outcome
Celli B. R. Chest 2008;133:1451-1462
Spirometry = COPD • Essential for diagnosis • SigniFicantly underutilized • Change in management occurs in >50% of patients with COPD when diagnosed in primary care practice
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Who Should Get Spirometry?
Smoker/ex-‐smoker >40 yrs old who says ‘yes ’ to: • Do you cough regularly? • Do you cough up phlegm regularly? • Do even simple chores make you short of breath? • Do you wheeze when you exert yourself, or at night? • Do you get frequent colds that persist longer than those of other people you know?
Approach to Patients with COPD
Celli B. R. Chest 2008;133:1451-1462
Approach to Patients with COPD
Celli B. R. Chest 2008;133:1451-1462
BODE Index: ClassiBication of Severity
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Approach to Patients with COPD
Celli B. R. Chest 2008;133:1451-1462
ClassiBication of Severity Severity of airflow limitation in COPD (based on postbronchodilatoe FEV1
From the Global Strategy for the Diagnosis, Management and Prevention of COPD 2013, Global Initiative for Chronic Obstructive Lung Disease (GOLD), www.goldcopd.org.
GOLD Guidelines: COPD Management
• Assess and monitor the disease • Reduce risk factors • Manage stable COPD • Manage exacerbations
COPD: a Treatable Disease
• Overall goals of treatment – to prevent further deterioration in lung function,
– improve symptoms and – quality of life, – treat complications, and – prolong a meaningful life
Celli B. R. Chest 2008;133:1451-1462
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COPD: a Treatable Disease • Improved survival found with:
– Smoking cessation – Long-‐term oxygen therapy in hypoxemic patients – Noninvasive mechanical ventilation in some patients with acute-‐on-‐chronic respiratory failure
– LVRS for patients with upper-‐lobe emphysema and poor exercise capacity
• The TORCH (Towards a Revolution in COPD Health -‐-‐ > 6,000 patients) – Combination of salmeterol and Fluticasone improved lung function and health status, AND
– Relative risk of dying decreased by 17.5% (over the 3 years of the study). • Pulmonary rehabilitation and lung transplantation improve symptoms and the quality of life
Celli B. R. Chest 2008;133:1451-1462
Therapeutic Options for Patients at Risk for COPD and Those With Established Disease
Celli B. R. Chest 2008;133:1451-1462
LAMA =LA muscarinic agent LVR = lung volume reduction MV = mechanical ventilation.
COPD: Importance of HyperinBlation
• Dyspnea perceived during exercise, including walking, more closely relates to the development of dynamic hyperinBlation than to changes in FEV1.
• Improvement in exercise brought about by several therapies (bronchodilators, oxygen, lung volume reduction surgery, and even rehabilitation) is more closely related to delaying dynamic hyperinFlations than by improving the degree of airFlow obstruction.
Celli B. R. Chest 2008;133:1451-1462
Approach To COPD Exacerbations (Increased SOB, Cough, Change in Color or Volume of Sputum)
Celli B. R. Chest 2008;133:1451-1462
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Approach To COPD Exacerbations (Increased SOB, Cough, Change in Color or Volume of Sputum)
Celli B. R. Chest 2008;133:1451-1462
Approach To COPD Exacerbations (Increased SOB, Cough, Change in Color or Volume of Sputum)
Celli B. R. Chest 2008;133:1451-1462
COPD: Corticosteroids • In outpatients, exacerbations necessitate a course of systemic corticosteroids (important to wean patients quickly)
• Standard doses of inhaled corticosteroid (ICS) aerosols, show minimal if any beneFits in the rate of decline of lung function.
• TORCH trial = combination of ICS and LABAs was superior to ICS alone (outcomes evaluated, including survival)
• Pneumonia (described as an adverse event but not precisely diagnosed) was more frequent in the patients receiving ICS
• ICS should not be prescribed alone but rather in combination with an LABA.
ASTHMA: Take Home Messages 1. Asthma is chronic inFlammatory disease of the airways; leads to hyperresponsiveness to stimuli that causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning.
2. Clinical manifestations of asthma can be controlled with appropriate treatment – there should be no more than occasional Flare-‐ups and severe exacerbations should be rare.
3. Measurement of lung function (spirometry of peak expiratory Flow) provide an assessment of the severity of airFlow limitation, its reversibility, and its variability, and provide conFirmation of the diagnosis of asthma.
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ASTHMA: Take Home Messages
4. Medications to treat asthma can be classiFied as controllers or relievers. – Controllers = medications taken daily on a long-‐term basis to
keep asthma under clinical control chieFly through their anti-‐inFlammatory effects.
– Relievers = medications used on an as-‐needed basis that act quickly to reverse bronchoconstriction and relieve its symptoms.
5. Inhaled glucorticosteroids are the most effective controller medications.
COPD: Take Home Messages 1. COPD is a common condition with a high mortality. 2. Smoking is most common risk factor. However, in many
countries, outdoor, occupational, and indoor air pollution (burning of biomass fuels) are risk factors.
3. Clinical diagnosis considered in any patient who has dyspnea, chronic cough or sputum production, and risk factors.
4. Spirometry is required to make diagnosis. 5. Appropriate pharmacologic therapy can reduce COPD
symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance.
COPD: Take Home Messages 6. For symptomatic patients with COPD, pulmonary rehabilitation and
maintenance of physical activity is useful to improve symptoms, exercise capacity, and quality of life.
7. Exacerbation of COPD is an acute event characterized by worsening of respiratory symptoms that are beyond normal day-‐to-‐day variations and leads to a change in medication.
8. Long-‐term oxygen therapy for all patients with COPD who have chronic hypoxemia.
9. All patients should be advised to quit smoking, educated about COPD, and given a yearly inFluenza vaccination.
10. In addition, the pneumococcal polysaccharide vaccine should be given to all patients with COPD.
THANK YOU FOR YOUR ATTENTION
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