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Transcript of Lynn M. Keenan, MD, FACP, FCCP Lynn M. Keenan, MD, FACP, FCCP Pulmonary/Critical Care Medicine...
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Lynn M. Keenan, MD, FACP, FCCPPulmonary/Critical Care Medicine
Northwest Hospital and Medical CenterWAPA
January 2013
Overview of COPD
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Disclosures
Speakers Bureau Boehringer Ingelheim I hate tobacco abuse I am a old SNL and Seinfeld Fan If you were here last year, I updated my jokes I miss “The Closer”, doesn’t everyone?
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Clinical Course of COPD
Air TrappingExpiratory Flow Limitation
Breathlessness
Inactivity
Poor Health-Related Quality of Life
Hyperinflation
Deconditioning
COPD
Disability Disease progression Death
Reduced Exercise Capacity
COPD
Exacerbations
Adapted from Decramer M. Eur Respir Rev. 2006;15:51-57.
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COPD Definition and Epidemiology
GOLD: Global Initiative for Chronic Obstructive Lung Disease
Goals: awareness, decrease mortality and morbidity
Improve prevention and management Systemic consequences: persistent systemic
inflammatory state leads to: Decreased fat-free mass, impaired systemic muscle
function, anemia, osteoporosis, depression, pulmonary hypertension, cor pulmonale
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COPD Definition and Epidemiology
Largest disease burden >age 40: 9-10 % adults, greater in men Affects 10% general population and 50%
heavy smokers > 80% pts. Under diagnosed survey 8,215 pts. 16 million people with 110,000 deaths 2010 3rd leading cause of death 2011 3% mortality for hospital admission 50% mortality for ICU admission within 2 years
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• High BODE index• Multiple severe exacerbations• CVD • Decreased FEV1
• Dyspnea• Hyperinflation (IC/TLC ≤ 25%)• Pulmonary hypertension• Impaired Exercise Performance• Depression• Low BMI
Predictors of COPD Mortality
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2 Million, Severe Disease*
10 Million
12+ Million at risk
and unidentified
SUBCLINICAL COPD
Clinical COPD – Tip of the Iceberg
Adapted from Mannino DM, et al. MMWR Morb Mortal Wkly Rep. 2002;51(SS06):1-16.
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Airflow Limitation Starts Before Symptoms are Evident
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COPD Definition and Epidemiology
Women >er mortality poorer prognosis with BMI of 25 and lower BODE
index Faster decline in FEV1 has a modest increased
risk of death and time to COPD related hospitalization
Severe COPD: increased mortality with more advanced age, lower BMI, oxygen supplementation, greater hyperinflation, also patients at increased risk lung cancer, atherosclerosis, and osteoporosis
Presence of chronic cough/sputum identifies a subgroup with higher risk of developing COPD, independent of smoking habits
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Question 1: Who is your average COPD patient?
The Marlboro man55 year old working woman85 yo man with ASCAD, and prostate
cancer80 yo retired Army thoracic surgeon
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Who does COPD Affect? Aunt Ann and my Dad.
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Really?
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My Aunt Carrie
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Seriously?
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It even looks like a fungus
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COPD Definition and Epidemiology
Risk Factors: cigarette smoking, Marijuana, alpha-1-antitrypsin deficiency, heavy occupational dusts, biomass fuels and chemical fumes, environmental tobacco smoke, lung growth (viral, fetal exposure)
Caused by interaction of noxious inhaled agents and host factors increasing neutrophils and macrophages
Toxic gases generate cytokines and chemokines control migration of inflammatory immune cells, leading to compromised repair of lung structure and function, increased apoptosis of endothelial and epithelial cells
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* Years after 2000 include adults aged ≥ 25y only
COPD Mortality
0
10000
20000
30000
40000
50000
60000
70000
1975 1980 1985 1990 1995 2000 2005 2010
Male
Female
Year
An
nu
al U
S D
eath
s
Mannino DM, et al. MMWR Morb Mortal Wkly Rep. 2002;51(SS-6):1-16.Brown DW, et al. MMWR Weekly. 2008;57(45):1229-1232
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COPD Immunology Small airways: inflammatory cell infiltrate,
remodeling thickens the airway and increases resistance to flow
Prominent inflammatory infiltrates in the alveolar walls, destruction of alveoli, and enlargement of air spaces
Inflammation mediated by T-cells persists after smoking cessation
Cigarette use increased oxidative stress
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24
Tamagawa E et al. Chest. 2006;130:1631-1633.
Lung Inflammation and Vascular DiseaseEffects of Lung Inflammation on Blood Vessels
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Normal Lungs and Lungs With COPD
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Manifestations of COPD
• Emphysema: pathologic diagnosis
• Hyperinflation
• Mucus hypersecretion (chronic bronchitis)
• Frequent exacerbations
• Severe hypoxemia
• Low BMI
• Skeletal muscle dysfunction
Papaioannou AI, et al. Respir Med. 2009;103:650-660. Celli BR. Proc Am Thorac Soc. 2006;3:461-465.
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Increased Risk for Cardiovascular Disease in COPD
MI = myocardial infarction, CHF = congestive heart failure, CVD = cardiovascular disease; All between-group differences P < 0.05 – adjusted for CV risk
Curkendall SM, et al. Ann Epidemiol. 2006;16:63-70.
21.1
11.2
5.6
31.3
9.6
70.4
22.8
11.7
6.43.2
9 7.9
54
11.2
0
10
20
30
40
50
60
70
80
Arrhythmia Angina Acute MI CHF Stroke Other CVD CVDHospitalization
Per
cen
t of
Subj
ects
COPD (N = 11,493)Controls (N = 22,986)
• Retrospective study of Canadian databases• Subjects age ≥ 40 years • Diagnosed with COPD during 1997–2000 • Received ≥ 2 Rx for dilators w/i 6 months
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The Risk of Osteoporosis in Caucasians With Obstructive Airways Disease
Sin DD, et al. Am J Med. 2003;114:10-14.
P = 0.005 for trends
1.93.9
6.8
11
7.610.3
20.9
33
0
5
10
15
20
25
30
35
None Mild Moderate Severe
Severity of Airflow Obstruction
Per
cen
t of
Su
bje
cts
wit
h
Ost
eop
oros
is
Men
Women
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Severe Obstructive Airway Disease Is Associated With Greater Risk of Fracture
de Vries F, et al. Eur Respir J. 2005;25:879-884.
0.2 0.5 1 2.0 5.0
Hip fracture
Osteoporotic fracture
Vertebral fracture
*Adjusted in patients with severe COPD for general risk factors, smoking status, duration of enrollment, and exposure to bronchodilators
ICS - No
ICS - Yes
ICS - No
ICS - Yes
ICS - No
ICS - Yes
Odds Ratio*
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Skeletal Muscle Dysfunction in COPD
Low muscle mass Poor capillarity Low muscle oxidative
enzyme activity Low fraction of type I fibers Muscle inflammation Corticosteroid myopathy Low levels of anabolic
hormones Vasoregulatory abnormalities
Lactate Increase During Exercise
Maltais F, et al. Am J Respir Crit Care Med. 1996;153:288-293.
VO2 (L/min)
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Testosterone
IGF-1
Insulinresistance
Negative energy balance
Hypoxemia
Steroidtreatment
Muscle protein breakdown
Muscle wastingand cachexia
Inflammation
Mechanisms of Muscle Wasting and Cachexia in COPD
Balasubramanian VP, Varkey B. Curr Opin Pulm Med. 2006;12:106-112.
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Pro
por
tion
Su
rviv
ing
Months of Follow-up
BMI (kg/m2)■ > 29● 24-29✴ 20-24▼ < 20
Low BMI Predicts Increased Mortality
• Cox proportional hazards model • Low BMI was an independent predictor of increased mortality (P < 0.001)• After stratification into BMI quintiles, the mortality risk was clearly
increased below 25 kg/m2
Schols AM, et al. Am J Respir Crit Care Med. 1998;157(6 Pt 1):1791-1797.
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Prevalence of Depression in COPD
Overlap between symptoms of depression and COPD (fatigue, sleep, appetite)1
Prevalence: 20%–60%1,2
Impact3
– Decreased functional performance– Lower QOL scores
Inadequate recognition and treatment1
1. Kunik ME, et al. Chest. 2005;127:1205-1211.2. Norwood R. Curr Opin Pulm Med. 2006;12:113-117.3. Felker B, et al. Gen Hosp Psych. 2001;23:56-61.
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Prognostic Impact of Pulmonary Hypertension
Oswald-Mammosser M, et al. Chest. 1995;107:1193-1198.
– – – mean PAP ≥ 25 mmHg–––– mean PAP < 25 mmHg
mean PAP > 18 mmHgmean PAP 18 mmHg
PAP: pulmonary artery pressure
Years w/o Hospitalization for Exacerbation
Kap
lan
-Mei
er E
stim
ates
Survival time, months
Su
rviv
al R
ate
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The Majority of Patients with COPD Are Among Working Age Population
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Employees With COPD Incurred >4 Times Higher Total Mean Healthcare Costs
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Patients with COPD often have Multiple Comorbid Conditions
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Comorbid Conditions in Patients with COPD Are More Likely to be Treated Than COPD
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Mortality Associated With COPD
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COPD Management
Prevent disease and progression Relieve symptoms Improve exercise tolerance Improve health status Prevent and treat complications Treat exacerbations Reduce mortality
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The COPD Population Screener (COPD-PS)
1. During the past 4 weeks, how much of the time did you feel short of breath?
2. Do you ever cough up any “stuff”, such as mucus or phlegm?
4. Have you smoked at least 100 cigarettes in your ENTIRE LIFE?
Yes
A little of the time
Some of the time
Most of the time
All of the time
None of the time
0 1 2 20
Only with occasional
colds or chest infections
Yes, a few days a month
Yes, most days a week
No, never Yes, every day
0 1 1 20
Disagree Unsure Agree Strongly agree
Strongly disagree
0 0 10 2
5. How old are you?
Don’t knowNo
0 2 0
Age 35 to 49 Age 50 to 59 Age 60 to 69 Age 70 +
1 2 20Martinez FJ, et al. COPD. 2008;5:85-95.
3. Please select the answer that best describes you in the past 12 months, I do less than I used to because of my breathing problems.
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Screening for COPD with Spirometry?
Lin K, et al. Ann Intern Med. 2008;148(7):535-543.
Current status Underrecognized
Spirometry screening
Overdiagnosis (other causes of symptoms)
Symptom screening
Overdiagnosis (asymptomatic
healthy)
1. Symptoms
2. Spirometry Appropriate diagnosis
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Global Strategy for Diagnosis, Management and Prevention of COPD
Diagnosis and Assessment: Key Points
A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease.
Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD.
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Need a Quality Test
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Spirometry: Obstructive DiseaseVolu
me,
liters
Time, seconds
5
4
3
2
1
1 2 3 4 5 6
FEV1 = 1.8L
FVC = 3.2L
FEV1/FVC = 0.56
Normal
Obstructive
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Spirograms and Flow Volume Curves
A- RestrictiveB- NormalC- Obstructive
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Flow volume loops:Normal vs. COPD
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:
Normal Flow volume loop vs. COPD
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MILD COPD
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Severe COPD
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Global Strategy for Diagnosis, Management and Prevention of COPD
Classification of Severity of Airflow Limitation in COPD*
In patients with FEV1/FVC < 0.70:
GOLD 1: Mild FEV1 > 80% predicted
GOLD 2: Moderate 50% < FEV1 < 80% predicted
GOLD 3: Severe 30% < FEV1 < 50% predicted
GOLD 4: Very Severe FEV1 < 30% predicted
*Based on Post-Bronchodilator FEV1
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Assess symptoms Assess degree of airflow limitation
using spirometry Assess risk of exacerbations
Assess comorbidities
Use history of exacerbations and spirometry. Two exacerbations or more within the last year
or an FEV1 < 50 % of predicted value are indicators of high risk
Global Strategy for Diagnosis, Management and Prevention of COPD
Assessment of COPD
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Global Strategy for Diagnosis, Management and Prevention of COPD
Assess Risk of Exacerbations
To assess risk of exacerbations use history of exacerbations and spirometry: Two or more exacerbations within the last year or an FEV1
< 50 % of predicted value are indicators of high risk.
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Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Assess symptoms Assess degree of airflow limitation using spirometry Assess risk of exacerbations
Combine these assessments for the purpose of improving management of COPD
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Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Ris
k
(GO
LD
Cla
ssif
icat
ion
of A
irfl
ow L
imit
atio
n)
Ris
k
(Exa
cerb
atio
n hi
stor
y)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1CAT < 10
4
3
2
1
mMRC > 2CAT > 10
Symptoms(mMRC or CAT score)
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Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
(C) (D)
(A) (B)
mMRC 0-1
CAT < 10
mMRC > 2CAT > 10
Symptoms(mMRC or CAT score)
If mMRC 0-1 or CAT < 10: Less Symptoms (A or C)
If mMRC > 2 or CAT > 10: More Symptoms (B or D)
Assess symptoms first
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Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPDR
isk
(G
OL
D C
lass
ific
atio
n of
Air
flow
Lim
itat
ion
)
Ris
k
(Exa
cerb
atio
n hi
stor
y)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1CAT < 10
4
3
2
1
mMRC > 2CAT > 10
Symptoms(mMRC or CAT score)
If GOLD 1 or 2 and only 0 or 1 exacerbations per
year: Low Risk (A or B)
If GOLD 3 or 4 or two ormore exacerbations per
year: High Risk (C or D)
Assess risk of exacerbations next
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Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Ris
k
(GO
LD
Cla
ssif
icat
ion
of A
irfl
ow L
imit
atio
n)
Ris
k
(Exa
cerb
atio
n hi
stor
y)
> 2
1
0
(C) (D)
(A) (B)
mMRC 0-1CAT < 10
4
3
2
1
mMRC > 2CAT > 10
Symptoms(mMRC or CAT score)
Patient is now in one offour categories:
A: Les symptoms, low risk
B: More symtoms, low risk
C: Less symptoms, high risk
D: More Symtoms, high risk
Use combined assessment
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Patient Characteristic Spirometric Classification
Exacerbations per year
mMRC CAT
ALow Risk
Less SymptomsGOLD 1-2 ≤ 1 0-1 < 10
BLow Risk
More SymptomsGOLD 1-2 ≤ 1 > 2 ≥ 10
CHigh Risk
Less SymptomsGOLD 3-4 > 2 0-1 < 10
DHigh Risk
More SymptomsGOLD 3-4 > 2 > 2
≥ 10
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
When assessing risk, choose the highest risk according to GOLD grade or exacerbation history
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COPD Risk: exacerbations, hospitalization, death
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CAT Scores: impact and management
< 10: low impact: smoking cessation, annual influenza vaccination, reduce exacerbation risk, therapy by clinical assessment
10-20: medium impact: add review maintenance therapy, refer pulmonary rehab, minimize exacerbation, review aggravating factors: smoking
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CAT Scores: impact and management
21-30:high impact: pt has significant room for improvement, consider referral to specialist, additional pharmacologic treatments
>30: very high impact: same as high impact
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Exacerbations Can Increase Healthcare Burden Associated With COPD
• Exacerbations of COPD can have negative impacts on patient lung function, health-related quality of life, and socioeconomic costs• Lung function declined more rapidly in patients with frequent exacerbations
• Direct medical costs for exacerbations associated with COPD remain at approximately $18 billion per year
1) The Global Initiative for Chronic Obstructive Lung Disease. GOLD Report—Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Updated 2009.; 2) Donaldson GC, Seemungal TA, Bhowmik A, Wedzicha JA. Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease. Thorax. 2002;57(10):847-852. ; 3)Anzueto A, Sethi S, Martinez FJ. Exacerbations of chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2007;4(7):554-564.
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Communication Is Essential to Monitoring Exacerbations
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Management of Exacerbations Associated With COPD
The Global Initiative for Chronic Obstructive Lung Disease. GOLD Report—Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Updated 2009.
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Impact of COPD
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The BODE Index
0 1 2 3
FEV1 (% predicted) 65 50-64 36-49 35
Distance walked in 6 min. (M) 350 250-349 150-249 149
MMRC dyspnea scale 0-1 2 3 4
BMI > 21 21
Variable Points on BODE Index
Celli BR, et al. N Engl J Med. 2004;350:1005-1012.
BODE = body mass index, obstruction, dyspnea, and exercise capacity; MMRC = Modified Medical Research Council
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Survival in COPDFEV1 Stage BODE
Months
1.0
0.8
0.6
0.4
0.2
0.00 4 8 12 16 20 24 28 32 36 40 44 48 52 0 4 8 12 16 20 24 28 32 36 40 44 48 52
Stage I (> 50%) predicted
Stage II (36-50%) predicted
Stage III ( 35%) predicted
Quartile 1 (BODE 0-2)
Quartile 2 (BODE 3-4)
Quartile 3 (BODE 5-6)Quartile 4 (BODE 7-10)
Pro
babi
lity
of
Surv
ival
P < 0.001 P < 0.001
Celli BR, et al. N Engl J Med. 2004;350:1005-1012.
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COPD DIFFERENTIAL
Asthma Congestive heart failure Bronchiectasis Verklempt
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More Than 50% of Patients With COPD Were Misdiagnosed With Asthma
Tinkelman DG, Price DB, Nordyke RJ, Halbert RJ. Misdiagnosis of COPD and asthma in primary care patients 40 years of age and over. J Asthma. 2006;43(1):75-80.
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Differential Diagnosis: COPD and Asthma
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COPD Management
Ongoing monitoring and assessment Progressive disease Follow up spirometry Monitor pharmacotherapy: therapeutics,
adherence, technique, effectiveness of controlling symptoms
Monitor exacerbation: frequency and severity
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Question 2: If a patient stops smoking the lung function improves
True False Maybe a little
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Smoking Cessation Can Slow COPD Onset and Progression
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Question 3: What 4 interventions improve survival in severe COPD?
1. Exercise, oxygen, beta agonists, nutrition
2. Exercise, oxygen, anticholinergics, nutrition
3. Exercise, oxygen, quitting smoking, inhalers
4. Exercise, oxygen, quitting smoking, nutrition
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Comprehensive Approach for COPD Management
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• Counseling• Nicotine replacement
– Gum
– Inhaler
– Nasal spray
– Transdermal patch
– Sublingual tablet
– Lozenge
Acidic Beverages (coffee)
• Bupropion• Varenicline
First Line Smoking Cessation Treatments
GOLD Guidelines 2008. http://www.goldcopd.com/Guidelineitem.asp?l1=2&l2=1&intId=2003. Accessed September 2010.
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Carbon Monoxide-Confirmed 4-Week Continuous Quit Rates Weeks 9–12
OR = 3.85*
OR = 1.93*
OR = 3.85*
OR = 1.90*
100
44.0 43.9
29.829.5
17.617.7
0
20
40
60
Study I Study II
Res
pon
se R
ate
(%)
Varenicline Bupropion Placebo
N = 352 N = 329 N = 344 N = 344 N = 342 N = 341
OR = odds ratio
*P < 0.001
Gonzales D, et al. JAMA. 2006;296:47-55. Jorenby DE, et al. JAMA. 2006;296:56-63.
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Smoking Cessation with Varenicline
Tx Period
Tashkin DP, et al. Chest. 2010 Sep 23. [Epub ahead of print]
1o Endpoint
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Adverse Event Varenicline0.5 mg BID
n = 129
Varenicline1 mg BIDn = 821
Placebon = 805
Nausea 16% 30% 10%
Insomnia* 19% 18% 13%
Abnormal Dreams
9% 13% 5%
Constipation 5% 8% 3%
Flatulence 9% 6% 3%
Vomiting 1% 5% 2%
Varenicline: Most Common Adverse EventsFrom 12-week Fixed-Dose, Placebo-Controlled Studies
* Includes Preferred Terms: Insomnia/Initial insomnia/Middle insomnia/Early morning awakening*
Varenicline package insert. Available at: www.pfizer.com/files/products/uspi_chantix.pdf. Accessed September 2010.
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• Psychiatric symptoms
– Changes in behavior
– Agitation
– Depressed mood
– Suicidal ideation
– Suicidal behavior• “Advise patients and caregivers that the patient should
stop taking CHANTIX (varenicline) and contact a health care provider immediately if agitation, depressed mood, or changes in behavior that are not typical for the patient are observed, or if the patient develops suicidal ideation or suicidal behavior.”
Varenicline Warning
Varenicline package insert. http://www.pfizer.com/files/products/uspi_chantix.pdf. Accessed September 2010.
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Nicotine Nasal Spray with Nicotine Patch for Smoking Cessation
Percentage (number) of participants abstinent from smoking at follow up
• 237 smokers followed for 6 years• Combination of a 5 month nicotine patch + nicotine nasal spray is
more effective for smoking cessation than the patch alone
Blondal T, et al. BMJ. 1999;318:285-288.
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• At every encounter, ask patient if he/she is still smoking, and chart response
• At every encounter, give strong advice to quit smoking• Measure expired CO (> 10 ppm) • Perform/order spirometry, use spirometry results and ‘lung age’
as leverage to advise smoking cessation• Ask patient if they are ready to quit and their history of attempts• Negotiate/impose a target ‘Quit Day’, have staff follow up that
day– Schedule follow-up appointments
• Refer patient to a behavioral support program or telephone quit line
• Prescribe pharmacological support as appropriate– NRT, bupropion SR, varenicline
Tips to Help Patients Quit Smoking
Adapted from Tashkin DP, and Murray RP. Respir Med. 2009;103:963-974.
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Short acting bronchodilators: B2 adrenergic agonist: albuterol, levalbuterolAnticholinergic agent: ipratropiumCombination: albuterol/ipratropium
Long acting bronchodilatorsB2 adrenergic agonists: salmeterol, formoterol,
aformoterol , IndacaterolAnticholinergic: tiotropium bromide, Aclidinium
Inhaled corticosteroids: fluticasone, budesonide, beclomethasone, mometasone
Combinations: fluticasone-salmeterol, budesonide-formoterol, mometasone-fomoterol
Methylxanthines: theophyllinePDE4 Inhibitor: RoflumilastAntibiotics: Azithromycin
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Rescue vs Maintenance Medication in Moderate COPD
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COPD Management: PharmacologicTheophylline
Theophylline: Thoracic Park Smooth muscle relaxation Fall in trapped gas volume Pulmonary vascular dilator Level 6-10 Studies: 110 patients 100mg bid over 1 year,
favorable, decreased exacerbations, decreased clinic visits, increased FEV1
42 Theophylline and 43 placebo
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COPD Management:Pharmacologic
Theophylline May act as nonselective phosphodiesterase inhibitors Significance is disputed Clearance of the drug decreases with age All studies were performed with slow release
preparations There is evidence to show greater improvement in
FEV1 when added to salmeterol than salmeterol alone
Toxicity: arrythmias, nausea, vomiting, seizure, GERD, plus multiple drug interactions
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PDE4 Inhibitor RoflumilastStudy Design
Anti-inflammatory action Previously shown to improve lung function but not
exacerbations Assess exacerbations in carefully selected patients Patients: confirmed COPD
Severe airflow limitation (FEV1/FVC ≤ 70%) Bronchitic symptoms History of exacerbations Current or former smokers (≥ 20 pack-year
history) > 40 years old
2 parallel identical studies
Calverley PM, et al. Lancet. 2009;374(9691):685-694.
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PDE4 Inhibitor Roflumilast 4 week run-in with placebo Randomization (Study M2-124 n = 1525; M2-125 n = 1571)
Roflumilast 500 mcg qd Placebo
52 weeks of treatment Permitted co-medications
LABA SABA Continuing short- or long-acting anticholinergics
Forbidden co-medications Inhaled CS New long-acting anticholinergics
1o endpoints Change in pre-bronchodilator FEV1
Rate of COPD exacerbations NO NOT GIVE IN COMBINATION with Theophylline
Calverley PM, et al. Lancet. 2009;374(9691):685-694.
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PDE4 Inhibitor RoflumilastResults
Calverley PM, et al. Lancet. 2009;374(9691):685-694.
M2-124 M2-125 Pooled
Rof Pbo Δ P Rof Pbo Δ P Rof Pbo Δ P
Δ pre-dilator FEV1 (mL) 46 8 39 0.0003 33 -25 58 < 0.0001 40 -9 48 < 0.0001
RR RR RR
Mean exac rate (per pt*yr)
1.08 1.27 0.85 0.028 1.21 1.49 0.82 0.004 1.14 1.37 1.37 0.0003
• Study confirms efficacy in selected patients with COPD
• No roflumilast effect on mortality or CRP levels
• Diarrhea, nausea, weight loss more common with roflumilast
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COPD Management: PharmacologicBeta Agonists
Sympathomimetics: Albuterol, Salbutamol, Levalbuterol, Salmeterol, Formoterol, Indacaterol
B2: bronchial smooth muscle: small and medium airways, stimulate beta2 adrenergic receptors
Improve mucocilliary clearance Increased response in combination therapy Cardiovascular effects, hypokalemia,
tachyphylaxis, lactic acidosis and respiratory failure
Dose: technique, spacer
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COPD Management: PharmacologicBeta Agonists
SABA: takes effect in 15-20 minutes and lasts 4 hours
LABA: Salmeterol: takes effect in 4 hours and lasts 12
hours Fomoterol: takes effect in 1 hour and lasts
12hours Indacaterol: takes effect in 1 hout and lasts 24
hours All significantly improve lung volumes, dyspnea,
health related quality of life, and exacerbation rate Aformoterol nebulized lasts 12 hours
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COPD Management: Pharmacologic Anticholinergics Muscarinic receptors Airway smooth muscle: M3 Chronic bronchitis and emphysema 2x -4x
increased cholinergic tone Atropine 1920’s, Ipratropium bromide 1980’s,
Tiotropium 2004- proximal bronchiole and bronchi, Aclidinium 2012
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Expiratory Airflow Limitation Leads to Air Trapping
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Airflow Limitation Leads to Air Trapping and Hyperinflation
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Hyperinflation
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COPD Management: Pharmacologic
Ipratropium Dosing: 4 puffs Q6 hours Combivent 1990’s: Albuterol + Ipratropium
FEV1 increased 31-33% over baseline Fewer exacerbations
Tiotropium Bromide- once daily long acting bronchodilator
Long acting antimuscarinic agent, M3 receptors, effect one hour and lasts 24 hours
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COPD Management: Pharmacologic
Minimal side effects: dry mouth, exacerbation glaucoma and constipation
Very safe Poorly absorbed
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Donahue et al:Indacaterol vs. Tiotropium
Evaluated Indacaterol vs. placebo and placebo and Tiotropium over 26 weeks
1,683 patients, Moderate to severe COPD, Indacaterol 150 mcg or 300 mcg
SGRQ, FEV1, and exacerbations post dose trough FEV1 increased 180 ml with
Indacaterol and 140 ml with Tiotropium SGRQ improved but not statistically
significant, no improvement in decreased exacerbations
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UPLIFT Trial
Time to first exacerbation: Tiotropium 16.5 months vs placebo 12.5 months
14% reduction in # exacerbations Tiotropium Mortality not statically significant 14.4% vs
16.3%
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Clinical Course of COPD
Air TrappingExpiratory Flow Limitation
Breathlessness
Inactivity
Poor Health-Related Quality of Life
Hyperinflation
Deconditioning
COPD
Disability Disease progression Death
Reduced Exercise Capacity
COPD
Exacerbations
Adapted from Decramer M. Eur Respir Rev. 2006;15:51-57.
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Question 5: what happens to your end expiratory lung volume with exercise?
A- increasesB- decreases
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Totallung
capacity
Tidal volume
Inspiratory reservevolume
Expiratory reservevolume
Residual volume
Inspiratory capacity
Vital capacity
Functional residual capacity
Lung Volume Terminology
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FRC
TV
IC
RV
Normal
Rest
Static and Dynamic Lung Volumes in COPD
Exercise
Rest
COPD
Exercise
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Lung Volume Response to Exercise
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4.5
5.0
5.5
6.0
6.5
7.0
7.5
8.0
0 5 10 15
Lung
vol
ume
(L)
Exercise time (minutes)
EELV
TLC
VT
IRV
Placebo
IC (1.92 L)
Operating Lung Volumes & Exercise Endurance Maltais et al
EELV
TLC
VT
IRV
IC (1.78 L)
Tiotropium
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Management: Aclidinium bromide
Long term management of COPD, chronic bronchitis, emphysema
LAMA, twice a day, muscarinic receptor M3 receptors
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Management: Aclidinium Bromide
Potential side effects: narrow angle glaucoma, urinary retention, cough, hypersensitivity to milk protein
Peak FEV1 improvements: 200mcg 235 ml and 400mcg 264ml
Trough FEV1 improvements: 200 mg 44 ml and 400mcg 109 ml
Sustained over 52 weeks
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COPD Management: Pharmacologic
Steroids: acute exacerbation of COPD favorable results and substantial benefits
Improvement in wheezing, air flow Improvement in abnormal mucus Trial for 2-3 weeks Demonstrate 20-30% improvement FEV1 Response to oral steroids poor predictor
respond to inhaled steroids
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COPD Management: Pharmacologic
Four large studies regular treatment with inhaled glucocorticosteroids appropriate for symptomatic COPD patients FEV1< 50% predicted
Treatment reduce frequency of exacerbations and improve health status
Benefit 25-50% of patients: improvement 6 minute walk
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TRIPLE THERAPY
Welte et al.:Efficacy and Tolerability of Budesonide/Formoterol Added to Tiotropium in Patients with Chronic Obstructive Pulmonary Disease
To assess the efficacy and tolerability of budesonide/formoterol added to tiotropium in patients eligible for inhaled corticosteroid/long-acting β2-agonist combination therapy.
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Triple Therapy
Over the treatment period, budesonide/formoterol plus tiotropium significantly increased predose FEV1 by 6% (65 ml) and postdose by 11% (123 and 131 ml at 5 and 60 min postdose, respectively) versus tiotropium alone (both P < 0.001). The number of severe exacerbations decreased by 62%. Both treatments were well tolerated.
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FEV1 With Triple Combination Therapy
1. Aaron SD, et al. Ann Intern Med. 2007;146(8):545-555. 2. Welte T, et al. Am J Respir Crit Care Med. 2009;180(8):741-750.
● BUD/FORM + TIO
■ PBO + TIO
Tio +/- Fluc/Sal1 Tio +/- Bud/Form2
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Exacerbations With Triple Combination Therapy
Tiotropium (n = 156)
Tiotropium + Salmeterol(n = 148)
Tiotropium + Salmeterol + Fluticasone
(n = 145)
% Pts with ≥ 1 exacerbations
62.8 % 64.8% 60.0%
Total Exacerbations 222 226 188
Exacerbations with Hospitalization
Incidence rate ratio compared with tiotropium + placebo (95% CI)
49 38
0.83(0.54 to 1.27)
26
0.53(0.33 to 0.86)
Aaron SD, et al. Ann Int Med. 2007;146(8):545-555.
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COPD Management: Pharmacologic Side effects : well recognized with steroids Inhaled steroids: oral thrush, hoarseness,
bruising Increased pneumonia with
fluticasone/salmeterol (TORCH trial) Triamcinolone increased risk of bone fracture Budesonide least absorbed, no effect on
bone mineral density Fluticosone/salmeterol;
mometasone/formoterol; budesonide/formoterol
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COPD Management: Pharmacologic Vaccines: influenza reduce the serious
illness and death in COPD by 50% Pneumococcal vaccine: 65 and older,
younger patients with COPD FEV1< 40%, reduction pneumonia
Alpha-1-antitrypsin augmentation therapy Smoking cessation: Varenicline, nicotine
acetycholine receptor agonist Mucolytics: controvertial, some evidence in
pts not on inhaled steroids N-acetylcyseine or carbocysteine may reduce exacerbations
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Management
Azithromycin: macrolide antibiotics have immunomodulatory and anti-bacterial properties
1142 COPD patients: randomized placebo to Azithromycin 250 mg daily
Azithromycin increased time to first exacerbation from 174 days to 266 days
37% decrease exacerbation rate
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Effects best in patients with more moderate GOLD II disease and former smokers
Increased hearing decrement 25% vs 20% 1 yr, no guidance for long term efficacy or
potential adverse effects of resistance Patients with tachycardia and prolonged QT
excluded
Management: Azithromycin
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COPD mortality is increasing Exacerbations are an important risk factor for
mortality Treatment with current drugs and combinations can
reduce exacerbations Currently available drugs alone and in combination
have been shown to have beneficial impacts on lung function and patient-centered outcomes in COPD and are useful in managing COPD.
No pharmacologic agent has thus far been shown to modify the persistence or progression of the underlying inflammatory/profibrotic/elastolytic pathology in COPD
Implications of Recent Trial Results
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COPD Management: Oxygen
1895: commercially produced liquid air 1920: hypoxia and right heart failure 1956: improves exercise capacity 1967: low flow O2 1968: improvement function in patients
receiving ambulatory O2 1970: long term home O2 increase survival 1980: O2 conserving device
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COPD Management: Oxygen
Mortality reduced in patients with RA PaO2 < 56 mmHg or O2 saturation < 88%
RA PaO2 < 60 mmHg with erythrocytosis, mental dysfunction, CHF, or cor pulmonale
Need therapy for 18-24 hours
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COPD Management: Oxygen
Improves quality of life, decreased hospitalization, improved psychomotor performance
Decreases pulmonary artery pressure
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Improved COPD Survival on LTOT
Güell Rous R. Int J Chron Obstruct Pulmon Dis. 2008;3(2):231-237. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93:391-398.Medical Research Council Working Party. Lancet 1981;1:681-686.
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COPD Management: Pulmonary Rehab
Reduces symptoms, improve quality of life, increased physical and emotional participation in life activities
Covers non pulmonary issues Respiratory muscles abnormal: inactivity,
systemic inflammation, malnutrition, increased work of breathing, impaired oxygen delivery, co morbid states, electrolyte imbalance, and drugs
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COPD Management: Pulmonary Rehab
Involve several health professionals Comprehensive exercise training Nutrition counseling Education
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Efficacy of Pulmonary Rehabilitation
0
50
100
150
200
250
Baseline 6 wks 1 yr
Griffiths TL, et al. Lancet. 2000;355:362-368.
02468
101214161820
Baseline 6 wks 1 yr
Control Rehabilitation
Walking DistanceDyspnea
•Patients participated in 3 half day sessions per week for 6 weeks in a multidisciplinary rehabilitation program including smoking cessation, occupational, physical, breathing, and diet sessions
•Physical therapy included 30 min sessions in-office as well as home sessions
–Treadmills, cycling, circuit training
P = 0.000
P = 0.017P = 0.000
P = 0.002
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COPD Management: Pulmonary Rehab
80 patients at LLUMC reduction from 19 to 6 days of hospitalization
Less time in hospital, fewer ER and office visits, return to work, increased ADL’s, more self care, decreased extended care and home care
Improved dyspnea and cough
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COPD Management: Nutrition
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Nutritional Supplements Have Not Increased Weight of Patients
Study
DeLetter 1991
Knowles 1988
Otte 1989
Rogers 1992
Schols 1995
Schols 1995a
Steiner 2003
Weekes 2004
18
13
13
15
39
33
25
30
N
17
12
15
12
25
38
35
25
N
Nutritional supplementation versus placebo or usual diet
Adapted from Ferreira IM, et al. Cochrane Database Syst Rev. 2009;(2):CD000998.
Standardized Mean Difference (Random)
9.2
7.2
8.1
7.8
12.9
13.9
12.6
11.9
Weight %95% CI
Total 214 205 100.0Test for overall effect Z = 1.25 P = 0.21
-4.0 -2.0 4.02.00Control better Supplement better
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LVRS: resection of functionless areas of emphysematous lung to improve mechanics
FEV1< 20% and either homogenous emphysema or DLCO < 20% high risk for death or unlikely to benefit
Increases exercise capacity not confer survival advantage
COPD Management: Surgery
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Yield advantage for patients both predominantly upper lobe emphysema and low baseline exercise capacity
Range of FEV1 improvement 250-350 ml Improved 6 minute walk $140,000 per quality-adjusted life year Resection of large bullae > 1/3 hemithorax Lung transplant
COPD Management: Surgery
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Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Non-pharmacologic
Patient Essential Recommended Depending on local guidelines
ASmoking cessation (can include pharmacologic
treatment)Physical activity
Flu vaccinationPneumococcal
vaccination
B, C, D
Smoking cessation (can include pharmacologic
treatment)Pulmonary rehabilitation
Physical activityFlu vaccinationPneumococcal
vaccination
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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 First choice Second choice Alternative Choices
ASAMA prn
or SABA prn
LAMA or
LABA or
SABA and SAMA
Theophylline
BLAMA
or LABA
LAMA and LABA SABA and/or SAMATheophylline
C
ICS + LABAor
LAMA LAMA and LABAPDE4-inh.
SABA and/or SAMATheophylline
D
ICS + LABAor
LAMA
ICS and LAMA orICS + LABA and LAMA or
ICS+LABA and PDE4-inh. orLAMA and LABA or
LAMA and PDE4-inh.
CarbocysteineSABA and/or SAMA
Theophylline
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Exa
cerb
atio
ns p
er y
ear
> 2
1
0
mMRC 0-1CAT < 10
GOLD 4
mMRC > 2CAT > 10
GOLD 3
GOLD 2
GOLD 1
SAMA prnor
SABA prn
LABA or
LAMA
ICS + LABAor
LAMA
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic TherapyFIRST CHOICE
A B
DCICS + LABA
or LAMA
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> 2
1
0
mMRC 0-1CAT < 10
GOLD 4
mMRC > 2CAT > 10
GOLD 3
GOLD 2
GOLD 1
LAMA or LABA or
SABA and SAMA
LAMA and LABA ICS and LAMA orICS + LABA and LAMA or
ICS + LABA and PDE4-inh orLAMA and LABA orLAMA and PDE4-inh.
LAMA and LABA
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic TherapySECOND CHOICE
A
DC
B
Exa
cerb
atio
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> 2
1
0
mMRC 0-1CAT < 10
GOLD 4
mMRC > 2CAT > 10
GOLD 3
GOLD 2
GOLD 1 Theophylline
PDE4-inh.SABA and/or
SAMATheophylline
CarbocysteineSABA and/or SAMA
Theophylline
SABA and/or SAMATheophylline
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Pharmacologic TherapyALTERNATIVE CHOICES
A
DC
B
Exa
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