Chronic Obstructive Lung Disease:GOLD GuidelinesBaylor College of MedicineCombined Med-Peds ProgramAnoop Agrawal, M.D.

COPD - DefinitionGlobal Obstructive Lung Disease Guidelines (GOLD) : first published in 2001Disease state characterized by airflow limitation that is no longer fully reversible and is usually progressive... This results in a chronic inflammatory response in the walls and lumen of the airways. GOLD guidelines were recently updated in 2006

COPD - PrevalenceAffects 15 million AmericansFourth leading cause of mortality (100,000/year)Only major health problem for which mortality has been increasing for past 20 yearsResults in 500,000 hospitalizations/yearSecond leading cause of missed work daysThere are numerous published guidelines - GOLD being the most prominent (www.goldcopd.com)

COPD - Risk FactorsHereditary - Alpha-1 Antitrypsin DeficiencyEnvironmentalCigarette SmokingWhat percent of smokers will develop COPD?15-20% (~1 in 5) - this implies a genetic predisposition to developing COPD; tends to cluster in familiesOccupational exposures to dust, chemicals

COPD - DiagnosisSymptoms chronic cough - intermittent, nonproductivecough with sputum production, smokers coughdyspnea on exertion, usually progressive and indolentSpirometry Should spirometry screening be performed on the general population?No, but in those with higher risk - i.e. all current and former smokers over the age of 40 years with any of the above symptoms of disease

The Importance of Screening for COPDThe Rule of 50s50% of COPD patients are undiagnosed (or approximately 12 million patients in U.S.)COPD is evident by age 50At time of diagnosis, FEV1 is

Raising COPD AwarenessNovember is National COPD Awareness MonthWorld COPD Day took place on November 19th, 2008.

COPD StagingBased upon the GOLD Guidelines - 2006 updateClassified into 4 stagesStaging is based primarily upon FEV1:FEV1 < 80%FEV1:FVC < 70%The lower the FEV1 the more severe the disease classification.

GOLD Guidelines for Therapy

COPD Management and TherapiesVaccination - pneumococcal and influenzaRegular Assessment of lung function - annuallyCessation of tobacco useDrug Therapy:short acting vs. long acting bronchodilatorsinhaled vs. oral corticosteroids

COPD - Management of Stable DiseaseSmoking cessation: rate of FEV1 deterioration will slow to near normal (20 ml /yr vs. 65 ml /yr for active smokers) if patient stops smoking

COPD - Drug TherapyTherapy recommendations based on their effect on FEV1.First Line therapy:Beta agonists - short and long actingAnticholinergics - short and long actingSecond Line therapy:Steroids - inhaled vs. oralSupplemental therapies

Beta agonistsMechanism of Action - bronchodilate by stimulating Beta-2 receptorsStudies show that COPD patients do not develop tolerance to short acting or long acting beta agonistsAsthmatics tend to develop tolerance to short acting agonists Can Salmeterol be used as monotherapy?YES, salmeterol monotherapy had adverse outcomes in asthma study, note copd.

DrugAlbuterolSalmeterolOnset1 to 3 min20 minDuration4 to 6 hrs12+ hrsB2:B1 selectivity1375:185,000:1

AnticholinergicsMechanism of action- bronchodilation by decreasing airway smooth muscle toneAlso reduces sputum productionCombination of an anticholinergic + B2-agonist produces greater and more sustained rise in FEV1 than either drug alone.

DrugIpratropiumTiotropiumOnset20 min?Duration4 to 8 hrs24+ hrsSelectivityAll MuscarinicM1 and M3> M2

Tiotropium (Spiriva)Studies show that once daily tiotropium has resulted in a lasting increase in FEV1 out to one year.174 ml above baseline in good short-term responders56 ml increase in poor short-term respondersTashkin,D. Chest 2003 May; 123:1441-9Special delivery device.

Inhaled Corticosteroids (ICS)Have not been shown to slow the progression of disease or provide long term benefitISOLDE trial - patients with FEV1 of 50% predicted value had a 25% reduction of exacerbationsCombination with salmeterol more effective in reducing exacerbations than either drug aloneUnfortunately, recently published trial failed to demonstrate statistically significant reduction in mortality with salmeterol/fluticasone combo.Use of ICS increases likelihood of pneumonia.

New COPD Treatment DataINSPIRE - study published in Jan 2008compared salmeterol/fluticasone head to head with tiotropiumNo difference in exacerbation rate although more in tiotropium group had higher drop out rate.More patients in salmeterol/fluticasone developed pneumonia.

Oral CorticosteroidsThey have no proven benefit in stable COPDOral steroids are useful for acute exacerbationsWhat is the recommended duration of therapy?Maximum benefit obtained during first 2 weeks of therapy.

Supplemental TherapiesSupplemental oxygen for hypoxemia (worn for more than 15 hrs/day) has been shown to reduce moratalityWhat are the qualification parameters for oxygen therapy?PaO2 of 55mmHg or less, or pulse oximetry of 88% or lessPulmonary RehabilitationLung reduction and lung transplantation surgeries

GOLD Guidelines for Therapy

SummaryEarly diagnosis, disease prevention, smoking cessation and vaccination are important.Initiate bronchodilator therapy early in disease course, combination of albuterol with ipratropium most effectiveInhaled corticosteroids may be useful in patients with severe disease or with objective responses on spirometry.Will likely see inflammatory modulators (TNF-) in the future