Nottinghamshire COPD and Asthma Guidelines

Dr Esther GladmanGP Prescribing Lead, Medicines

Management Nottingham City CCGFeb 2012

Where to find & other resources

• Google: Nottinghamshire Area Prescribing Committee

– Medicines Traffic Light Classification List– Shared Care Protocols– Clinical Guidelines – Formularies– Policies and Prescribing Position Statements

• E-healthscope• www.patient.co.uk• www.prodigy.nhs.uk (was CKS)

e.g. from prodigy : What simple measures can I advise to manage breathlessness for people with end-stage COPD?• Advise the person on the following simple measures to manage

breathlessness.– Sitting in front of a fan or open window (or using a hand-held fan).– Positioning

• For example, advise the person to sit or stand leaning forward (for example onto a table or the back of a chair) and supporting their weight with their arms and upper body.

– Pursed-lip breathing• Advise the person to inhale through the nose and then exhale slowly, for 4–

6 seconds, through pursed lips.

• Other simple measures, not specific to chronic obstructive pulmonary disease (COPD) but recommended in the section on Simple measures to help dyspnoea in the PRODIGY topic on Palliative cancer care - dyspnoea, may be useful for people with COPD.

Nottinghamshire COPD GuidelineKey points

• Most effective interventions• Be aware other conditions• Effective/cost effective prescribing• Steroid dose, pneumonia & adverse • Be aware side effects and adverse effects

of meds• Where can you make a difference?

Most Effective Interventions

• 1. Stopping smoking is the only treatment that slows the progression of COPDand is the most cost effective treatment in COPD. NNT 5 –to prevent death at age 70

• Motivational questioning, cost cigs & inhalers, Allen Carr, anxiety, dopamine,worsening of symptoms, dementia

Most Effective Interventions: 2. Pulmonary Rehabilitation

• MRC dyspnoea score 3, 4, 5 • or recent admission

“more breathless than contemporaries when walking or gets breathless on exertion & needs to rest”– NNT 2 to improve exercise tolerance by a clinically

useful amount– NNT 4 to stop readmission over 6/12 if given early

after an exacerbation

Most Effective Interventions3. Self Management Plans

• NNT 10 to reduce admission in low risk patients

• NNT 3 to reduce admission in high risk patients (1 previous admission or LTOT or previous use of Prednisolone)

• NNT 5 for patient held “emergency supply pack” (prednisolone +/- antibiotic) to reduce admission

Beware diagnosis• >40 years old• Smoker or ex-smoker, non-smoking spouse of

smoker or dusty occupation• Spirometry FEV1 < 80% predicted and post

bronchodilator FEV1/FVC ratio < 70% and typical symptoms

• NB FEV1 – an increase of >400ml after bronchodilator suggests asthma not COPD

• Consider CXR/FBC, ECG for alternative diagnoses or red flag symptoms such as haemoptysis

Be aware: are symptoms in accord with severity of COPD?

– FEV1 Rapid decline? e.g. >200ml in 3 years, exacerbations/Excess sputum

– Re-assess for co-morbidity, treatment adherence, inhaler technique

• Consider bronchiectasis • check sputum for unusual organisms/Acid &

Alcohol Fast bacilli• ? Ca CXR,FBC,ECG

• NB 25 % will have IHD/ cardiac failure

Effective/cost effective prescribing

• Stop smoking• Optimise inhaler technique (e.g. spacers

with MDIs)• Consider stopping new treatment if

patient feels no improvement (4 weeks)– longer may be needed for a reduction

in exacerbations• Consider stepping down/swopping

Effective/cost effective prescribing

• LABA vs LAMA – there is no significant difference re: reduction in exacerbation or hospitalisation rates.

Effective/cost effective prescribing

• There is no combination MDI licensed for COPD

• However if patient preference: –Fostair 100/6 (2 puffs BD £29.32) –or Seretide 125 + spacer (2puffs BD, £35)

can be considered, which gives similar ICS dose to Accuhaler 500.

• NB Seretide 250 MDI is not recommended

Adverse effects of steroid

• High dose ICS (ie fluticasone 1000 mcg = Seretide 250) increases the risk of pneumonia, NNH = 47 ie. Beware those with frequent exacerbations

• Other steroid effects - Diab/thrush/cataracts• Osteoporosis prophylaxis for patients having

4 courses of oral steroid within 12 months

Be aware side effects and adverse effects of meds

• Use tiotropium Spiriva Handihaler® (18 mcg/day) not Spiriva Respimat® (mist device)All patients must be advised not to exceed the maximum daily dose

• All anticholinergics have some cardiovascular effect

• Fometerol and beta agonists also have effect

NBs• Mucolytic only if troublesome phlegm:

carbocisteine 750mg TDS (£24.60) can be trialled for 4 weeks. – Stop if no effect. – Drop to maintenance dose: 750mg BD if effective.– Consider using in winter months only.– Mucolytics do not prevent exacerbations

• Consider theophylline 3rd line: Uniphyllin 200mg BD (£2.94) care with elderly & concomitant medications see BNF. Theophylline levels?

NNT=33

NBs

• 25% will have co-morbidity e.g. IHD/cardiac failure. Beta blockers can be used in COPD

• Dose of emergency supply pack?

Actions• Flu & pneumococcal vaccination• Inhaler use/Medication /step • Stop smoking advice /refer New Leaf• Patient info/empowerment• MRC dyspnoea score 3, 4 or 5/functional

disability refer for pulmonary rehabilitation• Self management plan and anticipatory

prescription pack• Weight/diet/exercise. Little & often leaflets

• Oxygen Sat ≤92% - refer to chest clinic /oxygen assessment service

• Palliative Care Planning If end-stage COPD/cor pulmonale

Nottinghamshire Adult Asthma Treatment Summary

• Micro break & shake

Nottinghamshire Asthma GuidelineKey points

• Step up and down• Use LABA and ICS in a combination inhaler• Be aware of inhaler equivalent steroid doses• Step 3a is addition of LABA not increase ICS too• Twitchiness of asthma• Same steroid risks as for COPD• Pros & cons of SMART• Theophylline levels/interactions

Step Consider stepping up if:

1. Using SABA 3 times a week or more

2. Symptoms 3 or > times x week

3. An exacerbation in the last 2 years

4. Waking due to symptoms one night a week

• Ensure adherence and inhaler technique

Consider stepping down if :

Asthma control has been good for 3 months on current therapy

N.B. Steroid dose reductions should be slow as patients deteriorate at different rates. Reduce by 25-50% & monitor

Appropriate spacer/ Other devices? Peak flow meter?

Step 3anb add LABA only

Step 3b & c

Step 3 alternative

SMARTPros: opener & reliever, inc dose steroid when need it Cons: device, symptoms, side effects

Step 4 asthma nb this is where use of Seretide 250 MDI is appropriate

nb

• Oral steroid - sometimes higher dose & shorter course than COPD

• Same steroid risks as for COPD• Written Self-Management

Plan/lifestyle/house dust mite/patient beliefs/info

• Co-morbidity

Key points summary

• Step up and down• Always give LABA and ICS in combination

inhaler (unlike COPD)

• Step 3a is addition of LABA not increase ICS too

• Be aware potency of ICS Inhaler and equivalent steroid doses