speaker slide resource copd...agenda • copd guideline and management • are all ics/labas the...
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Speaker Slide Resource COPD
Agenda
• COPD Guideline and Management • Are all ICS/LABAs the same in COPD? • Better Lung Deposition with Turbuhaler • Fulfil treatment with Rapihaler • Dose Recommendation in COPD
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GOLD 2017 Report: Chapters
© 2017 Global Initiative for Chronic Obstructive Lung Disease
1. Definition and Overview
2. Diagnosis and Initial Assessment
3. Evidence Supporting Prevention &
Maintenance Therapy
4. Management of Stable COPD
5. Management of Exacerbations
6. COPD and Comorbidities
Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases
Chronic Obstructive Pulmonary Disease (COPD), a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases
GOLD 2017: Updated COPD definition includes
persistent respiratory symptoms
GOLD 20172 GOLD 20161
COPD = chronic obstructive pulmonary disease; GOLD = Global Initiative for Chronic Obstructive Lung Disease 1. GOLD 2016
2. GOLD 2017
C O P D d e f i n i t t i o n
• COPD is a common preventtable and
ttreattable disease that is characterized by
persistent respiratory symptoms and
airftow limitation that is due to airway
and/or alveolar abnormalities usually
caused by significant exposure to noxious
particles or gases.
GOLD update 2017
COPD is caused by inhaled noxious agents, with lung damage
leading to airflow limitation
GOLD 2015
Inhaled noxious agents
(e.g. cigarette smoking, pollutants)
Obstruction and airflow limitation COPD = chronic obstructive pulmonary disease
Lung damage
Small airway disease: Airway narrowing and fibrosis
Mucus hypersecretion
(chronic bronchitis)
Parenchymal destruction: Loss
of alveolar attachments,
decrease in elastic recoil
(emphysema)
http://www.vapotherm.com/copd/
Accessed on: 12.12.2016
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Epidemiology of COPD in Thailand
GINA 2014 1. 1. COPD Guideline Thailand 2010 Available at www.thaichest.org 2. Chronic Diseases Surveillance Report, 2011, available at http://www.boe.moph.go.th
No data of national survey.
However based on data of the prevalence of smoking and pollutants in home environment and public places. It is estimated that COPD patient about 5 % of Thailand's population over the age of 30 years.
In the real survey from Thonburi province in population > 60 yrs, the prevalence and incidence of 7.1 percent and 3.6 percent respectively.
11 © 2017Global Initiative for Chronic Obstructive Lung Disease
GOLD 2017
COPD, a common preventable and treatable disease, is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormality usually cause by significant exposure to noxious particles or gases.
Definition of COPD
Diagnosis of COPD
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available at http://www.goldcopd.org/
TEXT TEXT
shortness of breath chronic cough
sputum
Tobacco Occupation
indoor/outdoor pollution
Symptom Exposure to the risk factors
SPIROMETRY: Required to establish diagnosis (Post-bronchodilator FEV1/FVC < 0.70 )
Back Up
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COPD Guideline and Management
The goals of COPD treatment remain unchanged in
GOLD 2017
• Relieve symptoms
• Improve exercise tolerance
• Improve health status
• Prevent disease progression
• Prevent and treat exacerbations
• Reduce mortality
Reduce symptoms
Reduce risk
COPD = chronic obstructive pulmonary disease; GOLD = Global Initiative for Chronic Obstructive Lung Disease
GOLD 2017
Mannino DM et al.Respiratory Medicine (2006) 100, 115–122
Exacerbations are more common with increasing
severity of the disease
Patients with two or more exacerbations during the year were considered to have frequent exacerbations
Hurst JR et al. N Engl J Med 2010;363:1128-38.
Frequent exacerbation increase mortality
particularly if these require admission to
hospital
Soler-Cataluña JJ et a.Thorax 2005;60:925–931.
AE with ER
AE with 1 admit
AE with readmit
No AE No AE
1-2 AE
≥ 3 AE
Exacerbations lead to downward spiral and death
COPD exacerbation: An event that negatively affects a patient’s baseline dyspnea, cough and/or sputum; and requires OCS, antibiotics and/or hospitalization
Increased symptoms (breathlessness)2
Increased risk of hospitalisation4
Increased risk of mortality4,5
Decline in lung function1
Worsening health status3
1. Donaldson GC, et al. Thorax 2002;57:847–852 2. Donaldson GC, et al. Eur Respir J 2003;22:931–936; 3. Seemungal TA, et al. Am J Respir Crit Care Med 1998;157:1418–1422 4. Groenewegen KH, et al. Chest 2003;124:459–467; 5. Soler-Cataluna JJ, et al. Thorax 2005;60:925–931.
GOLD 4 GOLD 3 GOLD 2
Jones PW. Journal of Chronic Obstructive Pulmonary Disease, 6:59–63
Weak correlation between FEV1 and SGRQ
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The goals of COPD treatment remain unchanged in
GOLD 2017
• Relieve symptoms
• Improve exercise tolerance Reduce symptoms
• Improve health status
• Prevent disease progression
• Reduce mortality
• Prevent and treat exacerbations Reduce risk
COPD = chronic obstructive pulmonary disease; GOLD = Global Initiative for Chronic Obstructive Lung Disease
GOLD 2017
Therapy at Each Stage of COPD I: Mild II: Moderate III: Severe IV: Very Severe
FEV1 > 80% pred
■
FEV1 < 80% ≥ 50% FEV1 < 50% ≥ 30%
FEV1 < 30% pred
or FEV1 < 50% pred
plus chronic
respiratory failure
Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed)
Add regular treatment with one or more long-acting bronchodilators
(when needed); Add rehabilitation
Add inhaled glucocorticosteroids if repeated exacerbations
Add long term oxygen if
chronic respiratory failure.
Consider surgical treatments
h1p://www.goldcopd.com/OtherResourcesItem.asp?l1=2&l2=2&intId=969
Postbronchodilator
Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy
(Medications in each box are mentioned in alphabetical order, and therefore not
necessarily in order of preference.)
LAMA and LABA PDE4-inh.
SABA and/or SAMA
Theophylline
ICS + LABA or
LAMA
ICS and LAMA or ICS + LABA and LAMA or
ICS+LABA and PDE4-inh. or
LAMA and LABA or LAMA
and PDE4-inh.
Patient Recommended first choice
(First choice)
Alternative choice
(Second choice)
Other possible treatment
(Alternative Choices)
A
SAMA prn
or
SABA prn
LAMA
or
LABA
or
SABA and SAMA
Theophylline
B
LAMA
or
LABA
LAMA and LABA
SABA and/or SAMA
Theophylline
C
ICS + LABA
or
LAMA
LABA and LAMA or LAMA
and PDE4-inh or LABA and
PDE4-inh
SABA and/or SAMA
Theophylline
D
ICS + LABA
and/or
LAMA
ICS + LABA and LAMA or
ICS+LABA and PDE4-inh. or
LAMA and LABA or
LAMA and PDE4-inh
Carbocysteine
NAC
SABA and/or SAMA
Theophylline
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic Therapy (Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order
of preference.)
Patient Recommended First
choice
Alternative choice Other Possible
Treatments
A SAMA prn
or SABA prn
LAMA
or LABA
or
Theophylline
B LAMA
or
LABA
LAMA and LABA SABA and/or SAMA
Theophylline
C ICS + LABA
or
LAMA and LABA or
LAMA and PDE4-inh. or LAMA LABA and PDE4-inh.
PDE4-inh SABA
and/or SAMA Theophylline
D ICS + LABA
and/or
LAMA
ICS + LAMA
ICS + LABA and LAMA or
ICS+LABA and PDE4-inh. or
LAMA and LABA or LAMA
and PDE4-inh.
Carbocysteine SABA
and/or SAMA
Theophylline
Maximizing Bronchodilatation
ICS for high risk group
Improve symptom and prevent exacerbation are the
key component
Patient Characteristic Spirometric
Classification
Exacerbations
per year
mMRC CAT
A Low Risk Less
Symptoms GOLD 1-2 ≤ 1 0-1 < 10
B Low Risk More
Symptoms GOLD 1-2 ≤ 1 > 2 ≥ 10
C High Risk Less
Symptoms GOLD 3-4 > 2 0-1 < 10
D High Risk More
Symptoms
GOLD 3-4
> 2
> 2
≥ 10
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment When assessing risk, choose the highest risk according to GOLD grade or exacerbation history. One or more hospitalizations for COPD exacerbations should be considered high risk.
GOLD update 2014
ABCD Assessment tool
© 2017Global Initiative for Chronic Obstructive Lung Disease
Management of Stable COPD
28
Pharmacologic treatment algorithms by GOLD grade
© 2017Global Initiative for Chronic Obstructive Lung Disease
29 © 2017Global Initiative for Chronic Obstructive Lung Disease
Pharmacologic treatment of Stable COPD
Bronchodilator
Evaluate
effect
Continue, stop or try
alternative class of
bronchodilator
Group A
A long-acting bronchodilator
(LABA or LAMA)
LAMA + LABA
Persistent
symptoms
LAMA + LABA
LAMA
Further
exacerbation(s)
LABA + ICS
LAMA LAMA + LABA LABA +ICS
+
+
LAMA
LABA
ICS
Consider macrolide
(in former smokers)
Consider Roflumilast
in FEV1 < 50% pred.
and patient has
chronic bronchitis
Persistent
symptoms/further
exacerbation(s)
Further
exacerbation(s)
Group B
Group C Group D
Further
exacerbation(s)
Do we still used ICS/LABA in COPD?
RISK BENEFIT
ICS
Exacerbation prevention ( ≥ exacerbation or ≥ 1 hospitalization) in the previous 12 months :
ICS/LABA and/or LAMA
Consider roflumilast in chronic bronchitis
Maintenance Rx : LAMA and/or LABA
Consider low dose sustained-release theophylline
Short acting inhaled reliever medication
salbutamol(SABA), ipratropium bromide(SAMA) or SABA+SAMA
Pharmacological
intervention Check device usage technique and adherence at each visit
Exacerbation No AE AE no corticosteroid/antibiotiecs AE requiring corticosteroid and/or
antibiotics., hospitalization
AE requiring corticosteroid and/ or
antibiotics., hospitalization
Symptoms
Breathlessness on severe
exertion,
Few symptoms.
No effect on daily activities
Breathlessness on moderate
exertion,
Few symptoms.
Little or no effect on daily
activities
Increasing dyspnea.
Dyspnea on minimal exertion.
Breathlessness walking on level
ground.
Increasing limitation of daily
activities
Cough and sputum production
Dyspnea at rest.
Severe limitation of daily
activities.
Chronic cough, regular sputum
production
mMRC 0-1 1-2 2-3 3-4
Lung function FEV1 ≥ 80% FEV1 50-79% FEV1 30-49% FEV1 ≤ 30%
Severity Mid Moderate Severe Very severe
Non-pharmacological Risk reduction : check smoking status, support smoking cessation, recommend annual influenza vaccine and pneumococcal vaccine.
intervention Encourage physical activity
Pulmonary rehabilitation program
Consider long term oxygen therapy, palliative care Thai COPD guideline 2560
Do we still used ICS/LABA in COPD?
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Thank You
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