Post on 01-Nov-2021
Asthma and COPD
How can you make a difference?
Disclosures
• Jo Congleton
• Consultant in Integrated Respiratory Care BSUH/SCFT
• Over the past few years I have given presentations at meetings and run educational training sessions for AstraZeneca and Boehringer Ingelheim
Overview
• What is asthma?• Current themes in treatment
• What is COPD?• Current themes in treatment
• Non-pharmacological treatments
• How can you contribute to management?
Medications Cost June 2012
Of the top 5 costliest drugs to the NHS, ALL are respiratory inhalers
• 5. Seretide 125 evohaler - £81 million/yr
• 4. Seretide 500 accuhaler - £85 million/yr
• 3. Symbicort 200 - £90 million/yr
• 2. Tiotropium - £120 million/yr
• 1. Seretide 250 evohaler - £180 million/yr
Airways narrowing due to
bronchoconstriction and
inflammation; duration and
severity are risk factors for
development of airway
remodelling and COPD
Airways collapse due to
destruction of alveolar walls
– may lead to bullae
Airways narrowing due to
Chronic irritation of the bronchi causing
inflammation and changes to the mucociliary
escalator; often results in chronic cough
Large airway
inflammation
Small
airwaysEmphysema
Fibrosis
Definition of COPD
COPD is predominantly caused by smoking and is characterised by
airflow obstruction that is not fully reversible
The airflow obstruction does not change markedly over several
months but is usually progressive in the long term
Exacerbations often occur, when there is a rapid and sustained
worsening of the patient’s symptoms beyond normal day-to-day
variations
NICE 2010
Definition of Asthma
• Asthma is a chronic inflammatory condition characterised by variable and reversible airway obstruction
• Eosinophilic bronchitis
Airways narrowing due to
bronchoconstriction and
inflammation; duration and
severity are risk factors for
development of airway
remodelling and COPD
Airways collapse due to
destruction of alveolar walls
– may lead to bullae
Airways narrowing due to
Chronic irritation of the bronchi causing
inflammation and changes to the mucociliary
escalator; often results in chronic cough
Large airway
inflammation
Small
airwaysEmphysema
Fibrosis
DiagnosisPatients over 35
Smokers or ex-smokers
With any of the following:
exertional breathlessness
chronic cough
regular sputum production,
frequent winter ‘bronchitis’
wheeze
C
O
P
D
NICE COPD Guidelines 2010
Diagnosis
Patients over 35
And no clinical features of asthma
Smokers or ex-smokers
With any of the following:
exertional breathlessness
chronic cough
regular sputum production,
frequent winter ‘bronchitis’
wheeze
C
O
P
D
NICE COPD Guidelines 2010
• Wheezy Child
• DV PEFR chart
• Day to day variation
• b2 reversibility
• Steroid reversibility
• Atopy, Family History
SMOKERS CAN HAVE ASTHMA
• Onset 35- 55yrs
• Flat PEFR chart
• Constant symptoms
• Progressive SOB
• Little / no reversibility
• Significant smoking history
ATOPICS CAN HAVE COPD
Does my patient have asthma or COPD?
Asthma COPD Overlap Syndrome? (ACOS)
• Many patients have features of asthma and COPD
• Older age group• Childhood asthma
• Significant smoking history
Other diagnoses to consider
• Bronchiectasis
• ILD
• Dysfunctional Breathing/Vocal cord dysfunction
• Heart Failure
Case VK
►68 year man
►Cough and SOB
►Cough 18 years, worse recently, egg cup of green sputum per day
►Breathlessness varies day to day
►Even a good day ex tol 30 yds
►Smoking History: 30 pk yrs, nil for 20 yrs
CASE VK
• Treatment had been escalated
• Now on ‘triple thereapy’
• ICS component high dose
• No significant response to treatment
Asthma Management
• New BTS/SIGN guideliines
Inhaled steroid use and Asthma Death
0
0.5
1
1.5
2
2.5
0 1 2 3 4 5 6 7 8 9 10 11 12
No. of canisters of inhaled
corticosteroids per year
RR Death fromAsthma
Moving up and moving down
Adapted from British guideline on the management of asthma. 2016. Available from: https://www.brit-thoracic.org.uk/document-library/clinical-
information/asthma/btssign-asthma-guideline-quick-reference-guide-2016/ (accessed Oct 2016)
• Initial add on therapy:• LABA plus low dose ICS – usually combination
• Consider maintenance and reliever therapy
• Additional add on therapies• Stop LABA and move to medium dose ICS
• Continue LABA, move to medium dose ICS
• Continue LABA/ICS and trial LTRA
• Continue LABA/ICS and trial SR theophylline
• Continue LABA/ICS and trial LAMA (unlicensed)
Adapted from British guideline on the management of asthma. 2016. Available from: https://www.brit-thoracic.org.uk/document-library/clinical-
information/asthma/btssign-asthma-guideline-quick-reference-guide-2016/ (accessed Oct 2016)
Consider moving up therapy if using 3 or more doses
of rescue β2 per week
ICS Doses
• Low: Beclometasone 100mcg 2puffs bd
• Medium: Beclometasone 200mcg 2 puffs bd
• High Dose: Beclometasone 200mcg 4 puffs bd
Adapted from British guideline on the management of asthma. 2016. Available from: https://www.brit-thoracic.org.uk/document-library/clinical-
information/asthma/btssign-asthma-guideline-quick-reference-guide-2016/ (accessed Oct 2016)
High dose therapies
• High dose ICS
• Addition of a 4th drug:• LTRA
• SR theophylline
• Beta agonist tablet
• LAMA
• REFER PATIENT FOR SPECIALIST CARE
Adapted from British guideline on the management of asthma. 2016. Available from: https://www.brit-thoracic.org.uk/document-
library/clinical-information/asthma/btssign-asthma-guideline-quick-reference-guide-2016/ (accessed Oct 2016)
COPD Management
• Aim of treatment:
to relieve symptoms
reduce the risk of exacerbations
• Reduce risk of death
QoF COPD Cases: B+H CCG (predicted 10,711)
3400
3500
3600
3700
3800
3900
4000
COPD
2011/12
2012/13
2013/14
2014/15
Private and confidential
27
Case FindingPatients over 35
Smokers or ex-smokers
With any of the following:
exertional breathlessness
chronic cough
regular sputum production,
frequent winter ‘bronchitis’
wheeze
C
O
P
D
NICE COPD Guidelines 2010
COPD Management
• Relieve Symptoms
• Reduce Risk of Exacerbations
• Reduce risk of death
• Bronchodilators
• Pulmonary Rehabilitation
• LABA/ICS
• Bronchodilators
• Pulmonary Rehabilitation
• Smoking Cessation
• Smoking Cessation
• LTOT
Risk Symptoms Exacerbations
High risk, less symptoms
ICS/LABA or LAMA
High risk, more symptoms
ICS/LABA
(triple therapy)
Low risk, less symptoms
SABA or SAMA
(LABA or LAMA)
Low risk, more symptoms
LAMA or LABA
(LAMA + LABA)
30
Exacerbator
2 or more per
year
Non-exacerbator
0 or 1 per year
mMRC <2 mMRC 2 or more
AFO: FEV1
< 50% pred
AFO: FEV1
> 50% pred
mMRC2 = MRC 3 Walks slower than most people on the level, stops after a
mile or so, or stops after 15 minutes walking at own pace
Triple Therapy
£35,000-£187,000
LABA
£8,000/QALY
LAMA
£7,000/QALY
Pulmonary Rehabilitation
£2,000-8,000/QALY
Stop Smoking Support with pharmacotherapy £2,000/QALY
Flu vaccination £?1,000/QALY in “at risk” population
The Value Pyramid
VBAT
• Very Brief Advice Training
• http://www.ncsct.co.uk/publication_very-brief-advice.php
Triple Therapy
£35,000-£187,000
LABA
£8,000/QALY
LAMA
£7,000/QALY
Pulmonary Rehabilitation
£2,000-8,000/QALY
Stop Smoking Support with pharmacotherapy £2,000/QALY
Flu vaccination £?1,000/QALY in “at risk” population
The Value Pyramid
Pulmonary RehabilitationA structured programme combining:
• supervised exercise training (the core of PR)
• a comprehensive educational programme
• psychosocial support ATS/ERS Guidelines 2006
ACCP/ AACVPR Evidence-Based Clinical Practice Guidelines 2007
Evidence for Pulmonary Rehabilitation
Improvements in multiple outcomes of
considerable importance to the patient:
Dyspnoea
↓SOB for a given amount or intensity of activity
Exercise capacity
Health Related Quality of Life
up to 9/12 post PR
NICE Guidelines 2004,2011; ATS/ERS Guidelines 2006
Lacasse 1997, 2004; Cambach 2002; Griffiths 2003
ACCP/ AACVPR Evidence-Based Clinical Practice Guidelines 2007
Medicines Optimisation:Opportunities
• Reduce ICS burden
• Rationalising inhaled therapies and reducing cost
• Referring for PR early to defer need for higher level meds
• Joint working: local pharmacists, community teams, primary care
• Joint formularies
• Clear consistent messages
Value Pyramid
Seretide Accuhaler ®(Salmeterol & Fluticasone propionate)
Symbicort Turbohaler ®(Formoterol & Budesonide)
DuoResp Spiromax ®(Formoterol & Budesonide)
Symbicort ® – Formoterol& Budesonide))
Relvar Ellipta ®▼ – (vilanterol & Fluticasone Furoate)
Long Acting Bronchodilators and
Inhaled Corticosteroids
MDINEXThaler
AirFluSal Forspiro ®(Salmeterol & Fluticasone propionate)
Fostair ® – (Formoterol & Beclometasone)
ICS and Pneumonia
• All studies have shown an increased risk of community acquired pneumonia with high dose ICS
• Aim to keep ICS burden as low as possible
Anoro Ellipta ®▼(Vilanterol & Umeclidinium)
Duaklir Genuair ®▼(Formoterol & Aclidinium)
Ultibro Breezhaler ®▼(Indacaterol & Glycopyrronium)
Long acting bronchodilators and long acting muscarinics
Spiolto Respimat ®▼(Oldaterol/ Tiotropium)
Risk Symptoms Exacerbations
High risk, less symptoms
ICS/LABA or LAMA
High risk, more symptoms
ICS/LABA
(triple therapy)
Low risk, less symptoms
SABA or SAMA
(LABA or LAMA)
Low risk, more symptoms
LAMA or LABA
(LAMA + LABA)
42
Exacerbator
2 or more per
year
Non-exacerbator
0 or 1 per year
mMRC <2 mMRC 2 or more
AFO: FEV1
< 50% pred
AFO: FEV1
> 50% pred
mMRC2 = MRC 3 Walks slower than most people on the level, stops after a
mile or so, or stops after 15 minutes walking at own pace
Does my patient have asthma or COPD?orWhat is this Asthma COPD Overlap Syndrome? (ACOS)
• Many patients have features of asthma and COPD
• Older age group• Childhood asthma
• Significant smoking history
• Main therapeutic difference is to use LAMA earlier (than if pure asthma)
• And to use lower doses of ICS (than if pure COPD)
Asthma COPD and Asthma-COPD Overlap Syndrome (ACOS) 2014 – www.ginasthma.org
wp-content/uploads/20
15/03/Drugs-and-Devices-Aprilm-
2015.pdf45
46
The correct inhaler device….
• …Is the one that the patient is able to use and will use
• There is no place for an ICS containing mdi without a spacing device
Relative lung dose, shown as maximal plasma salbutamol concentration (Cmax), from the early lung absorption
profile over the first 20 minutes following inhalation of a 1200 μg nominal dose of salbutamol.
STEPHEN J FOWLER, and BRIAN J LIPWORTH Thorax 2000;55:345
Copyright © BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.
Tips for pharmacists
• If dispensing an ICS or ICS combination always ask if patient has and is using a spacing device
• Alert if dispensing frequent SABA prescriptions (especially asthma)
• If dispensing high dose ICS flag up to GP/patient
• If you know/think the patient has asthma are you dispensing 1 device per month?
• Always ask about inhaler technique
• Consider promoting non-pharmacological treatments• SSS• PR• Self Excerise• Influenza VAc