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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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