COPD MANAGEMENT · 2019. 1. 6. · – LAMA/ICS has not been compared to LAMA alone ... FQ if complicated COPD or 1 or more risk factor. Who needs steroids? Oral glucocorticoids decrease

COPD MANAGEMENT

Assessment of disease severity ■  Severity of airflow limitation (spirometric grade)

■  History of exacerbations

■  Assessment of dyspnea and symptoms (using mMRC or CAT)

Non-pharmacologic Management

■  Smoking cessation* ■  Influenza ■  Pneumococcal vaccines

–  PPSV23 in those <65 yo, PCV13 in those >65 yo ■  Pulmonary rehabilitation (B-D) ■  Oxygen therapy* ■  Surgery?

Short acting bronchodilators

■  Recommended in less symptomatic, low risk patients (GOLD A), either monotherapy or combination

■  SABAs: proven to improve symptoms and lung function, no added benefit when used as a regularly scheduled medication

■  SAMAs: similar effectiveness to SABA, some studies showed better effect on FEV1 and symptoms.

■  Combined therapy > monotherapy in terms of FEV1

Long acting bronchodilators ■  First choice in more symptomatic/low risk (GOLD B) or less

symptomatic/high risk (GOLD C)

■  LABAs: proven to improve symptoms and lung function, decreases exacerbations and hospitalizations. No evidence of mortality benefit. Salmeterol is the most well studied.

■  LAMAs: overall similar efficacy and safety compared to LABA, but greater effect at reducing exacerbations. Combined LABA/LAMA in patients with uncontrolled symptoms showed better quality of life in increased FEV1 –  Adding a 2nd long acting bronchodilator is preferred over an inhaled

corticosteroid (ICS)

Inhaled Corticosteroids ■  No role for ICS monotherapy

■  ICS can be added to LABA in moderate/severe COPD with repeated exacerbations or a component of asthma/inflammation, more effective than LABA alone – improved outcomes compared to LABA alone –  ICS use associated with adverse effects such as fungal infections, skin

bruising, respiratory infections

■  LABA/LAMA (glycopyrronium-indacaterol) > ICS/LABA (fluticasone-salmeterol) in terms of preventing exacerbations –  Separate study showed LABA/LAMA superior in terms of lung function –  LAMA/ICS has not been compared to LAMA alone

**Remember oral glucocorticoids can be used in the management of acute COPD exacerbations but have no role in chronic therapy

Triple Therapy: LABA/LAMA + ICS

■  Multiple studies have demonstrated the benefit of triple therapy in patients with severe disease

■  Most recent study in 2018 (IMPACT): 10637 patients with moderate/severe COPD (CAT ≥10), GOLD 2-4 with multiple exacerbations –  Triple therapy decreased rate of exacerbations and

hospitalizations compared to dual therapy. Trend towards decreased all cause mortality.

■  Recommended in those with persistent symptoms, frequent exacerbations despite LABA/LAMA or LABA/ICS.

Theophyllines

■  Occasionally used in those with refractory COPD, exact mechanism is controversial

■  Has been shown to improve lung function compared to placebo in stable COPD

■  Combination with LABA improves lung function compared to LABA alone

■  Narrow therapeutic index, many drug interactions

■  Not recommended for use in acute COPD exacerbations

Phosphodiesterase-4 Inhibitors

■  Used for patients with severe COPD with chronic bronchitis and history of frequent exacerbations (at least 2/year or 1 requiring hospitalization)

■  Limited benefit on lung function, should be used to prevent moderate/severe exacerbations

■  Drug interactions (antiepileptics, antibiotics)

Chronic Antibiotic Prophylaxis

■  Studies show reduction in exacerbations without improvement in lung function, hospitalizations or mortality

■  Should not be used in most patients with COPD

■  Can be considered in those with frequent exacerbations despite optimal medical therapy

■  Azithromycin is the recommended antibiotic, Moxifloxacin has shown efficacy but avoided due selection of FQ resistant bacteria

A patient present to you in clinic for management of his COPD. He has a 30 pack year smoking history. He has never been hospitalized and his last exacerbation was 1 year ago. Spirometry shows FEV1 of 70% and post-bronchodilator FEV1/FVC of 65%. His mMRC score is 3. How would you manage this patient?

This patient would be classified as GOLD B (low risk, more symptomatic, GOLD 2 spirometric classification) - Should be started on a short acting bronchodilator prn + a long acting bronchodilator (do not use SAMA + LABA together)

A patient presents to you in clinic for COPD management. Spirometry shows FEV1 35 and patient has had 2 hospitalizations due to exacerbations in the past year. His only current medication is albuterol, which he uses 4 times per day. Patient states he has difficulty walking more than a few feet due to shortness of breath. How do you adjust his medication regimen?

This patient would be classified as GOLD D (high risk, more symptomatic, GOLD 3 spirometric classification) - SABA or SAMA alone recommended in only in GOLD A. - Given the severity, the patient should be started on LABA/LAMA, SABA prn (do not use LAMA + SAMA together). - Consider adding ICS

Combivent/Duoneb = Albuterol/ipratropium ProAir/Proventil/Ventolin = Albuterol Spiriva = Tiotropium Serevent = Salmeterol Anoro, Stiolto, Utibron, Bevespi = LABA/LAMA Advair = Fluticasone/salmeterol

Management of Acute Exacerbations

Who needs antibiotics?

Patients with 2 of the 3 following: increased shortness of breath, increased sputum production and increased purulence.

-Macrolide if uncomplicated COPD without risk factors (age<65, FEV1>50, no cardiac disease, <2 exacerbations/year). FQ if complicated COPD or 1 or more risk factor.

Who needs steroids?

Oral glucocorticoids decrease rate of relapse/symptoms and improve lung function. All patients with acute exacerbations receive Prednisone 40mg (or equivalent) for 5 days.