Asthma-COPD Overlap Syndrome - ACOS
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Transcript of Asthma-COPD Overlap Syndrome - ACOS
ASTHMA - COPD
Dr. Nino JN DoydoraSection of Pulmonary Medicine
ASTHMA - COPD
DisclosuresNovartis A 52-week Treatment, Multi-Center, Randomized, Double-Blind, Parallel-Group and active Controlled Study to
Evaluate the Effect of QVA149 (110/50 ug o.d.) vs NVA237 (50 ug o.d.) and Open Label Tiotropium (18 ug o.d.) on COPD exacerbations in Patients with Severe to very Severe COPD October 2010-October 2011
A 26-week Treatment, Multi-Center, Randomized, Double-Blind, Parallel-Group and active Controlled (open label) Study to assess the efficacy, safety and tolerability of QVA149 (110/50 ug o.d.) in Patients with Moderate to Severe COPD May–October 2011
Utsuka
Objectives:Review GINA 2014 guidelines on AsthmaReview the GOLD 2014 guidelines on COPD
EpidemiologyPathophysiologySigns and symptomsDiagnosis Treatment
Approach to a patient with ACOS (Asthma-COPD Overlap Syndrome) GINA 2014
CASE 119 year old female studentCC: 3 days cough, wheezing, SOB
Precipitated by exercise (frisbee)Relieved by salbutamol nebulization (past 3
nights)Self medicated with prednisone 10mg 1 dose
(+) history of asthma attacks during childhood(+) family Hx of asthma (mother)(+) Hx of atopy and (+) allergy to crustaceansPE: talks in sentences with occasional wheeze
Asthma
A reversible obstructive airway disease due to bronchial muscle constriction and airway inflammation; characterized by cough, wheezing and shortness of breath.
Resolves spontaneously or with use of rescue meds.Exacerbations are caused by triggers.
1 of 10 Filipino adults3 of 10 Filipino Children
ASTHMA – levels of controlCharacteristic Controlled Partly controlled Uncontrolled
Daytime symptoms: wheezing, cough, SOB
None >2x/week >3x/week
Limitation of activities none any anyNocturnal awakening none any anyNeed for reliever meds < 2x / wk >2x/wk >2x/week
ACT – ASTHMA CONTROL TEST
< 20 – suggests poor Asthma control
ACT – ASTHMA CONTROL TEST
< 20 – suggests poor Asthma control
DiagnosticsSpirometry – measures certain lung volumes; useful in diagnosing
obstructive lung patternsPeak flow – screening test; measures maximum speed of expiration
Peak flow
Patient’s Peak flow showed 65% from predicted
TreatmentNon-pharmacologic
Patient educationInhaler techniquePulmonary Rehabilitation Program
PharmacologicOral medicationsInhaled medications
Commonly used Inhaled treatments for Asthma & COPDCommonly used Inhaled treatments for Asthma & COPD
Short Acting BronchodilatorShort Acting B2 Agonist agent (SABA) = Salbutamol,
TerbutalineShort Acting Anti-Muscarinic agent (SAMA) = Ipratropium
Bromide
Long Acting BronchodilatorLong Acting B2 Agonist agent (LABA) = Salmeterol,
Formoterol, indacaterolLong Acting Anti-Muscarinic agent (LAMA) = Tioptropium
Inhaled Corticosteroid (ICS) = Fluticasone, Budesonide, beclomethasone
Combination: SABA + SAMA = Salbutamol + Ipratropium (Pulmodual)
Combination: LABA + ICS Salmeterol + Fluticasone (Adeflo) Formoterol + Budesonide
Treatment Patient education Inhaler technique and adherence to medications
STEP 1 STEP 2 STEP 3 STEP 4 STEP 5Preferred Controller Choice
NONE Low Dose ICS(Inhaled Steroid)
Low doseICS-LABA(ADEFLO)
Medium/HighICS-LABA(ADEFLO)
Refer for add on treatment
(anti-IgE)
Other ControllerOptions
-- LTRA or methylxanthines
(montileukastOr Theophylline)
Medium/HighICS-LABA OR
Low dose ICS/LABA + LTRA or /+ Theophylline
High DoseICS-LABA +
LTRA or Theophylline
Low dose oral steroid
RELIEVER SABA – short acting B2-agonist (Salbutamol)
Strategies to ensure effective use of inhaler devices
CHOOSEMost appropriate device
The medication neededAvailable devicesCostPatient skills and patient’s choice
Ensure no physical barriers, e.g. arthritisAvoid use of multiple different inhaler
types to avoid confusion
2014
Strategies to ensure effective use of inhaler devices
2014
Clinicians should be able to demonstrate correct technique for each of the inhalers they prescribe
For MDIs - use a spacer Improves deliveryReduces potential side-effects of ICS
Home meds and plans:Inhaled corticosteroid
May add oral steroid for 3-5 daysRound the clock reliever use for a few days then give on PRN basisIf symptoms worsen :
Follow-up in 3-5 days with chest X-rayAssess other possible causes of exacerbation
Follow-up 2 weeks – 1 month after consultMeasure peak flow on succeeding visits6-12 months of ICS therapy
Case 2:72 year old housewifeCC: on and off cough, wheezing, shortness of breath
Relieved by salbutamol nebulization lately is more bothersome after hosting a
birthday partywith grayish sputum, difficulty sleepingHas consulted several doctors; has 4 inhaler
devices Passive smokerPreviously hospitalized due to asthma 3 months agoPE: talks in phrases, (+) wheezing both lung fields
Case 2:
77 female smoker
Inhalers:•Tiotropium handihaler LAMA
•Salbutamol MDI SABA
•Procaterol swinghaler SABA
•Formoterol + Budesonide turbohaler ICS-LABA
•Budesonide turbohaler ICS
COPD: 2014 GOLD Definition
Pink Puffer
Blue Bloater
COPD
characterized by airflow limitation that is not fully reversible and is usually progressive
preventable and treatableexacerbations & co-morbidities contribute to the overall
severity © 2014 Global Initiative for Chronic Obstructive Lung Disease
CUASES of COPD
SMOKING1 pack/dayIn 10 years
PollutionExposure to Hazardous chemicals
Do we often see these COPD patients?
Pink Puffer
Blue Bloater
COPD prevalenceamong Filipinos > 40 yo:
20% 20% Idolor et al. Respirology 2012.
Mortality comparisons with COPD exacerbation and AMI
3
50
35
69
0 20 40 60 80
No Shock
Shock
Moderate
Severe
%
COPD Myocardial Infarction
Swedish Registry 2008, GUSTO-1 Trial 2007
How do we know they have COPD?
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Acute exacerbation in COPDIncreased symptoms
Reduced lung function
Accelerate lung function decline
Deteriorate quality of life
Increased economic cost
Increased mortality
Impact of acute
exacerabations in COPD
“an acute event characterized by worsening of respiratory
symptoms that is beyond normal day-to-day variations and leads
to a change in medication.”
GOLD Strategy Document 2014 (http://www.goldcopd.org/)
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Vicious Cycle of Inflammation-Oxidative Stress-Exacerbations in COPD
Oxidativestress
Anti-proteinase-Proteinase imbalance
COPD Pathology:
Exacerbations
• Cigarette smoke• Occupational dust & fumes• Biomass fuels
• Small airway fibrosis• Emphysema• Mucous hypersecretion
• Systemic manifestations
Modified British Medical Research Council (mMRC) Dyspnea Scale
COPD Assessment Test : CATI never cough I cough all the time
I have no phlegm (mucus) in my chest at all My chest is full of phlegm
My chest does not feel tight at all My chest feels very tight When I walk up a hill or one flight When I walk up a hill or one flight of stairs I am not breathless of stairs I am very breathless I am not limited doing any activities at home I am very limited doing activities at home I am confident leaving my home despite my I am not at all confident leaving my home lung condition because of my lung condition I sleep soundly I don't sleep soundly because of
my lung condition I have lots of energy I have no energy at all
COPD Assessment Test : CATI never cough I cough all the time
I have no phlegm (mucus) in my chest at all My chest is full of phlegm
My chest does not feel tight at all My chest feels very tight When I walk up a hill or one flight When I walk up a hill or one flight of stairs I am not breathless of stairs I am very breathless I am not limited doing any activities at home I am very limited doing activities at home I am confident leaving my home despite my I am not at all confident leaving my home lung condition because of my lung condition I sleep soundly I don't sleep soundly because of
my lung condition I have lots of energy I have no energy at all
SCORE: 35
COPD treatment: 2 MAIN GOALSGoals for treatment of stable COPD
Relieve symptomsImprove exercise toleranceImprove health statusAndPrevent disease progressionPrevent and treat exacerbationsReduce mortality
REDUCE SYMPTOM
S
REDUCE RISK
of exacerbation
Global Strategy for the Diagnosis, Management and Prevention of COPDGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2014
THERAPEUTIC OPTIONSWhat is the single most effective intervention to slow the progression of COPD?
1Home
Oxygen
2Pulmonary
Rehab.
3Smoking
Cessation
4Flu
Vaccination
Evidence A
How to start Treatment*Newly Diagnosed COPD PatientActive Reduction of Risk Factors
1. Smoking Cessation
2. Vaccination- Yearly Influenza ; Pneumococcal Vaccine every 5 years As Needed SABA or SABA/SAMA or if patient may benefit from OD/ bid treatment use
LABA or LAMA Assess : symptoms and RISK:
Pulmonary Rehabilitation Long Acting Bronchodilator
LABA alone (indacaterol) or LAMA alone (Tiotropium) Assess: More Symptoms low Exacerbation Risk
Add another Long acting bronchodilator LABA + LAMA or LAMA + LABA
Assess: More Symptoms, High Exacerbation Risk Progressive & Frequent Exacerbation
+ ICS LAMA + LABA + ICS
Adjunctive: Pulmonary rehabilitation, O2 treatment Surgical Options
•Based on Pharmacologic first choice treatment, GOLD 2011• other treatment options available.
ICS- inhaled steroid: fluticasone/budesonide/beclomethasone SABA – Salbutamol; SAMA – Ipatropium; LABA – Indacaterol; LAMA- Tiotropium SABA+SAMA – Salbu+IpBr (Pulmodual) OR *ICS+LABA – Fluticasone+Salmeterol (Adeflo)
Pharmacological Management of COPDPatien
tFirst Choice Second Choice Alternative Choice
ASABA or SAMA prn SABA and SAMA
LABA or LAMATheophylline (Option: Doxofylline )
BLABA or LAMA LABA and LAMA
SABA and /or SAMATheophylline (Option: Doxofylline )
CICS +LABA or LAMA LABA and LAMA
PDE4 InhibitorSABA and/ or SAMATheophylline(Option: Doxofylline )
DICS+ LABA and LAMA
ICS + LAMA ICS + LABA + LAMAICS and LABA and PDE 4 inhLABA + LAMALAMA + PDE 4 inh
CarbocisteineSABA and/ or SAMATheophylline(Option: Doxofylline )
PulmodualDilatair
Dilatair
Dilatair
Dilatair
Adeflo
Adeflo
GUIDED ASTHMA SELF-MANAGEMENT EDUCATION AND SKILLS TRAINING
Inhaler use is a skill - must be learned and maintainedUp to 70–80% are unable to use their inhaler
correctly. Unfortunately, many health care providers
are unable to correctly demonstrate how to use the inhalers they prescribe
Most people with incorrect technique are unaware that they have a problem
There is no ‘perfect’ inhaler - patients can have problems using any inhaler device
2014
Strategies to ensure effective use of inhaler devices
2014
Clinicians should be able to demonstrate correct technique for each of the inhalers they prescribe
For MDIs - use a spacer Improves deliveryReduces potential side-effects of ICS
Miat Monodose DPI
Twist
A New Twist to FDC ICS-LABA Inhaler Therapy
Passive DPI (aerolizer) breath actuated compact, portable, easy to
use no hand-mouth coordination
required Inhalation by capsule loaded by the
patient 40 capsules/ box Lactose carrier IFR > 60 lpm; no breath hold Protect from humidity
Sims MW. Chest 140(3):781–788, 2011.Laube BL, ERS/ISAM Task Force on Inhalational Therapy. Eur Respir J 37: 1308–1331, 2011.
Labris NR, Dolovich MB. Br J Clin Pharmacol 56: , 600–612, 2003.
50/250 mcg50/500 mcg
Salmeterol xinafoate/ Fluticasone propionate (Adeflo) via Adehaler
Dry Powder Inhaler
Dry Powder Inhaler
Wrong Right
Case 355 year old, male, teacherCC: cough, wheezing, shortness of breath 7 days
Precipitated by exposure to dust (he rides a motorbike)
Sneezing, itchy throatUnable to sleep due to SOB, partially relieved by
salbu neb(+) history of childhood asthma(+) 20 pack year (current) smoker(+) history of antibiotic (Co-amox) intake 4 weeks ago after diagnosed with
pneumonia as outpatient.PE: talks in sentences, (+) wheezing both lung fields
What will you give to this patient?A. SABA (Salbutamol PRN)B. ICS (Budesonide)C. LAMA (Tiotropium)D. LABA (Indacaterol)E. ICS+LABA (Fluticasone + Salmeterol)
ACOS (Asthma-COPD Overlap)
For a patient, count the number of checked boxes in each column. If 3 or more are checked for either asthma or COPD , that diagnosis is suggested. But if there are similar numbers of checked boxes in each column, ACOS should be considered.
ACOS (Asthma-COPD Overlap)
Spirometry:
ACOS (Asthma-COPD Overlap)
Approach to ACOS (Asthma-COPD Overlap Syndrome)
Asthma >> ICS (Inhaled corticosteroid)COPD >> LABA (long acting B2 agonist)ACOS >> ICS + LABA
Approach to ACOS (Asthma-COPD Overlap Syndrome)At least among adults, ACOS might represent a severe form of asthma,
characterized by greater risk of hospitalizations and exacerbationsACOS is likely the result of early asthma that has progressed to fixed
airway obstruction because airway remodeling and of its interaction with smoking
Treatment may prevent a steeper decline of lung function among ACOS.
De Marie Et. Al. ERS 2013 Presentation
Patient Education
SMOKER'S PRAYER
Heavenly Father, hear my plea, and grant my lungs serenity.
Give me strength to kick the smoking that's been causing all my choking.
Let my breath be fresh and clean without a trace of nicotine. Each ciggie I smoke so often
Adds another nail in my coffin Guide me Lord, by Your holy means past all those cigarette machines.
It hurts to hear My Loved ones say kissing ya's like lickin' an ashtray.
Please oh Lord, Hear my voice, give me will power, while I have a choice.
I ask Your help and it's no wonder because if I don't quit, I'm six feet under.
Health Is wealth
Thank you!