- Roflumilast and Azithromycin have been shown to decrease exacerbations in moderate to severe COPD patients... Thank you for this opportunity and for your time and attention..[r]
(1)COPD Assessment and Treatment Strategies Based on the Latest
GOLD Guidelines
Steven E Lommatzsch, M.D. Pulmonary and Critical Care
(2)Learning Objectives
Describe the GOLD recommendations for the combined assessment of COPD
Differentiate high risk COPD patients from low risk patients in your practice
(3)Background
In 1998 the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was implemented to increase diagnosis and improve management and prevention of COPD
In 2001 GOLD released ‘Global Strategy
for the Diagnosis, Management and Prevention of COPD’
Various updates have taken into account new concepts and emerging research
(4)(5)How to Diagnose COPD
Symptoms
Shortness of breath
Chronic cough
Chronic sputum
History of exposure to risk factors
Tobacco smoke
Home cooking/biomass fuels
(6)Perform Spirometry
The diagnosis of COPD relies on the demonstration of airflow limitation with post bronchodilator FEV1/FVC < 0.7
FEV1 = Forced expiratory volume in 1st second GOLD severity based on FEV1
GOLD Mild FEV1 ≥ 80% predicted
(7)Is FEV1 the Best Marker for Severity Assessment of COPD?
Jones et al COPD 2009;6:59-63
Poor Health
(8)Combined Assessment of COPD Severity
Assessment of airflow limitation
Assessment of symptoms
(9)Combined COPD Assessment* Risk (GO LD S ta ge of A irflow Li mi ta tion) Risk (Exa c erba tion hi st ory ) > 0-1 (C) (D) (A) (B) mMRC 0-1 CAT < 10
3
2
1
mMRC > 2 CAT > 10
*Choose the highest risk according to GOLD stage or exacerbation history
_Symptoms
50<FEV1<80 30<FEV1<50
(10) There are several validated questionnaires available to assess symptoms
GOLD recommends:
Modified British Medical Research Council
Questionnaire (easier to use)
COPD Assessment Test (broader coverage of impact)
(11)Assessment of Symptoms
Modified British Medical Research Council Questionnaire (MMRC) dyspnea score
0 No shortness of breath except for strenuous exercise
1 Short of breath hurrying on level or walking up a hill
2 Have to stop when walking on level
3 Stop for breath after 100m or few minutes on level Too breathless to leave the house or to perform daily
(12)Assessment of Symptoms COPD Assessment test (CAT)
8 item measure of health
status
Score -5 Impact
<10 – low
11-20 – medium 21-30 – high
31 - 40 – very high
0 Cough
0 Phlegm
0 Chest tightness Short of breath on hill or
flight of stairs
5
0 Limitation in home activities
5 Confidence leaving home
0 Sleep
0 Energy
(13)Assessment of Exacerbation Risk
Exacerbations increase decline in lung function,
health status and the risk of death
Greatest risk factor for future exacerbations is a history of previous exacerbations
(14)From OLD to New Classification
The old GOLD system of classification and
treatment made recommendations based only on the severity of lung dysfunction from spirometry (GOLD stages I – IV)
The new GOLD system of classification and
treatment is based on an integrated approach, and considers all three: spirometry, symptoms, and
(15)Example: Combined COPD Assessment* Risk (GO LD S ta ge of A irflow Li mi ta tion) Risk (Exa c erba tion hi st ory ) > 0-1 (C) (D) (A) (B) mMRC 0-1 CAT < 10
3
2
1
mMRC > 2
CAT > 10
*Choose the highest risk according to GOLD stage or exacerbation history
_Symptoms
50<FEV1<80
30<FEV1<50
(16)(17)www.goldcopd.org
• Relieve symptoms
• Prevent disease progression • Improve exercise tolerance • Improve health status
• Prevent and treat complications • Prevent and treat exacerbations • Reduce mortality
(18)Treatment of Stable COPD
1 - Smoking Cessation
2 - Pharmacologic Treatment - Pulmonary Rehabilitation - Oxygen Therapy
(19)1 - Smoking Cessation - Smoking cessation is a key
component to preserving lung function, and no other therapy impacts the natural disease progression more
- The most proven therapy for smoking cessation is a
multifaceted approach of support networks, nicotine replacement, and agents like bupropion and varenicline
(20)Adapted from Fletcher CM, Peto R Br Med J 1977;1:1645 20 Age (years) Death Disability Symptoms Not Susceptible Susceptible Smokers
Stopped smoking at 45 (mild COPD)
Stopped smoking at 65 (severe COPD)
30 40 50 60 70 80 90 20
(21)Smoking Cessation Therapy
Varenicline 2mg/day Buproprion SR
NRT Nasal Spray NRT Patch
NRT Gum
NRT Patch + Buproprion SR NRT Patch +Spray
NRT – nicotine replacement therapy
USPHS 2008 meta-analysis
33.2% 24.2% 26.7% 23.4% 19.0% 28.9% 25.8%
(22)2 - Pharmacologic Treatment
(23)2 - Pharmacologic Treatment
- The GOLD recommendations are guided by assessing lung function, symptoms, and exacerbations
- Appropriate therapy is dependent upon each patient’s needs and responses to
(24)Treatment based on Combined COPD Assessment* Ris k (GO LD Classific at ion of A irflow Lim ita tion) Risk (Exa ce rbat ion history ) > 0-1 (C) (D) (A) (B) mMRC 0-1 CAT < 10
3
2
1
mMRC > 2 CAT > 10
*Choose the highest risk according to GOLD stage or exacerbation history
SAMA prn or
SABA prn
_Symptoms
50<FEV1<80 30<FEV1<50
(25)Category A : Pharmacologic Treatment
- Short acting bronchodilators are integral to management of symptoms
- Short acting agents alone are not
recommended for patients with more
sustained daily symptoms or experiencing more frequent exacerbations
- Combination therapy results in synergistic
effects.
(26)Treatment based on Combined COPD Assessment* Ris k (GO LD Classific at ion of A irflow Lim ita tion) Risk (Exa ce rbat ion history ) > 0-1 (C) (D) (A) (B) mMRC 0-1 CAT < 10
3
2
1
mMRC > 2 CAT > 10
*Choose the highest risk according to GOLD stage or exacerbation history
SAMA prn or
SABA prn
_Symptoms
(27)Category B : Pharmacologic Treatment
- Long acting bronchodilators are
recommended for all patients with daily symptoms
- They are more effective for symptom relief than short-acting bronchodilators
(28)Treatment based on Combined COPD Assessment* Ris k (GO LD Classific at ion of A irflow Lim ita tion) Risk (Exa ce rbat ion history ) > 0-1 (C) (D) (A) (B) mMRC 0-1 CAT < 10
3
2
1
mMRC > 2 CAT > 10
*Choose the highest risk according to GOLD stage or exacerbation history
SAMA prn or
SABA prn
_Symptoms
50<FEV1<80 30<FEV1<50
FEV1>80%
FEV1<30% ICS + LABA
and/or
LAMA
LABA
or
(29)Category C & D : Pharmacologic Treatment
- These two groups are treated similarly
because of the increased exacerbation risk in both Thus, therapy attempts to decrease risk of exacerbations
- As the distinguishing feature between C and D is symptoms, the chosen therapy should be that which best relieves the patient’s
(30)Additional Choice – Medical Management
1 - Roflumilast (phosphodiesterase-4 inhibitor) is
approved in chronic bronchitic patients with frequent exacerbations, and an FEV1 < 50%, to help decrease the exacerbation rates
Lancet 2009 Aug 29;374(9691):685-94
2 - Chronic daily Azithromycin has also been proven to decrease exacerbation rates
(31)Chronic Azithromycin Therapy*
*Albert et al N Engl J Med 2011 Aug 25; 365:689-698
(32)3 - Pulmonary Rehabilitation
- Physical therapy has been underutilized by providers, and it is one of the most proven interventions to help with dyspnea
- Therapy typically consist of exercise training, education, nutritional interventions, and
psychosocial support
(33)n=93
(34)4 - OxygenTherapy
- Oxygen therapy is the most well established intervention to afford greater survival to the COPD patient
- It is indicated once PaO2 is less than 55 mmHg, and the goal is keep sats > 88% during rest, sleep, and exertion
(35)Oxygen Improves Survival in COPD Oxygen Improves Survival in COPD
Flenley DC Chest 1985:87:99
Lancet 1981:1:681
NOTT Trial Group Ann Intern Med
1980:16936:391
NOTT study:
COT – Continuous oxygen (17.7hr) NOT – Nocturnal oxygen
MRC trial:
O2 – “nocturnal” oxygen (15hr) Controls – no oxygen
(36)Mortality in subjects with: Upper lobe disease and low exercise capacity
1218 severe COPD patients Assessment
– CT distribution
– Exercise performance Randomize
– Surgery
– Medical management Re-evaluate: months, yearly Assess
– Survival – Exercise
Fishman A, et al N Engl J Med 2003;348:2059-2073
Lung Volume Reduction Surgery in Emphysema: NETT trial
(37)- The National Emphysema Treatment Trial (NETT ) - Volume Reduction Surgery (LVRS) with upper lobe predominate emphysema, FEV1 < 45% of predicted, gas trapping, no significant pulmonary hypertension, and DLCO and FEV1 values of greater than 20%
- LVRS improved functional status, physiologic parameters, and quality of life as compared to the medically managed group
- Lung Volume Reduction Surgery was shown to offer
substantial survival to those patients who had low exercise tolerance post rehabilitation
(38)- Lung transplantation is a consideration for those patients with considerable disability despite maximal medical therapy
- Factors Include:
Age < 65 years No cancer in the last years No Hepatitis B, C, HIV No tobacco in last months No severe osteoporosis No substances abuse
Reliable support network No major organ dysfunction BMI in range (<30) No advanced coronary
disease
(39)Treatment of Comorbidities
- It is important to remember these disorders and treat accordingly
- Cardiovascular disease (most common)
- Diabetes (especially with frequent steroid use) - Lung cancer (close to 10-fold greater in subjects
with severe COPD) - Osteoporosis
(40)- Brief Summary of Medical
Management Assess symptoms, spirometry, and exacerbation risk to characterize each patient and individualize therapy
- Use frequency of exacerbations (> 2/yr) and/or an FEV1 < 50% of predicted to indicate higher risk patients that
should be on combination inhaled steroids/long acting b -agonist and/or long acting antimuscarinic, or a
combination
(41)