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Improving Outcomes in COPDUpdates 2018
Neil MacIntyre MD
Duke University
Durham NC
Improving Outcomes in COPD
• COPD – pathophysiology, clinical picture/impact
• Diagnosis and staging
• Evidence based management guidelines
• Barriers to implementation
. Barnes PJ. N Engl J Med. 2000;343:269-80.
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COPD spectrum
• Proximal predominant (large airways)
– mucus gland hypertrophy (cough/sputum)
– reduced respiratory drive
– airway hyper-reactivity
• Distal predominant (small airways/alveoli)
– dyspnea - active respiratory drive
– reduced DLCO
COPD spectrum
table
Emphysema Bronchitis
COPD: the clinical spectrumCOPD is a systemic disease
• Chronic airway inflammation “spills” inflammatory cytokines into the circulation
– ASCVD
– Renal insufficiency
– Neuro-myopathy
– Osteoporosis
• Cachexia, debility may be product of this
Resp Care. 2006; 51: 840-8
COPD natural history depends on tobacco exposure/sensitivity
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0.0
0.5
1.0
1.5
2.0
2.5
3.0
CoronaryHeart Disease
Stroke Other CVD COPD All OtherCauses
-59% -64% -35% +163% -7%
COPD Projected to Be the Third-Leading Cause of Death by 2020
Proportion of 1965-1998 Rate, Percentage Change in Age-Adjusted Death (US)
Global Initiative for Chronic Obstructive Lung Disease teaching slide kit. Available at: www.goldcopd.com/slides/download.ppt.
Pro
po
rtio
n o
f 19
65 R
ate
COPD: Direct Cost
$0
$2
$4
$6
$8
$10
$12
$14
$16
$18
$20
COPD
Nursing Home Care*
Home Health Care*
Physician Services
Hospital Care
Prescription Drugs
Morbidity and Mortality: 2002 Chart Book on Cardiovascular, Lung, and Blood Diseases. NIH/NHLBI. May 2002.
†
Improving Outcomes in COPD
• COPD – pathophysiology, clinical picture/impact
• Diagnosis and staging
• Evidence based management guidelines
• Barriers to implementation
SYMPTOMSsputum
cough
dyspnea
wheezing
EXPOSURE TO RISK
FACTORS
SPIROMETRY
Diagnosis of COPD
Adapted with permission from the GOLD web site. Available at: www.goldcopd.com.
AND/
OR
SpirometryCOPD: the spirogram
Normal
Obstructed
Restricted
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Global Obstructive Lung Disease (GOLD) Consortium Staging
www.goldcopd.com
Spirometry can miss emphysema
In COPDgene, 357 of 858 smokers with normal spirometry had emphysema on CT
Symptoms/function as important as FEV1 on survival
BODE: Dyspnea, 6MWT, BMI, FEV1
GOLD 2017: Combined Assessment of COPD
• Diagnose COPD
– Spirometry not enough
– Radiology (hyperinflation, emphysema) and DLCO alternate diagnostic tools
• Two components determine severity of disease
– Symptom assessment
– Risk of exacerbations
CAT = COPD assessment test; mMRC = modified Medical Research Council.Global Initiative for Chronic Obstructive Lung Disease. 2014. http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. Accessed March 6, 2014.
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
Ris
k(G
OLD
Cla
ssif
icat
ion
of
Air
flo
w L
imit
atio
n)
Ris
k(E
xace
rbat
ion
his
tory
)
> 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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GOLD 2017
1)Diagnose 2) Obstruction Severity 3) Impact
Improving Outcomes in COPD
• COPD – pathophysiology, clinical picture/impact
• Diagnosis and staging
• Evidence based management guidelines
• Barriers to implementation
GOLD Guidelines 2017Guided by impact – not physiology
Global Strategy for Diagnosis, Management and Prevention of COPD
Manage Stable COPD: Non-pharmacologic
PatientGroup
Essential Recommended Depending on localguidelines
Indacaterol Arcapta Neohaler 1 inhaled capsule daily 24+ h
Salmeterol Serevent Diskus 1 puff bid 12+ h
HFA = hydrofluoroalkane.
http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=fbe6d514-9d89-48f7-80a0-d1b41983f203. Accessed April 3, 2014. Cazzola M, et al. Drugs Today. 2011;106:84-90. http://www.pdr.net/. Accessed April 3, 2014. PL Detail-Document, Inhalers for COPD. Pharmacist’s Letter/Prescriber’s Letter. August 2013.
Current Inhaled Medications for COPD Cont’d
Medication Brand Usual Starting Dose Duration
Anticholinergics
Short-acting
Ipratropium bromide Atrovent 2 puffs qid 6-8 h
Long-acting
Aclidinum Tudorza Pressair 1 puff bid 24+ h
Tiotropium bromide Spiriva Handihaler 1 inhaled capsule daily 24+ h
Combination Bronchodilators
Albuterol/ipratropium Combivent 2 puffs q 4-6 hrs PRN 4-6 h
Umeclidinum/Vilanterol Anoro Ellipta 1 puff daily 24 h
http://www.pdr.net/. Accessed April 3, 2014. Salmon M, et al. J Pharmacol Exp Ther. 2013;345(2):260-70. Slack RJ, et al. J Pharmacol Exp Ther. 2013;344(1):218-30. PL Detail-Document, Inhalers for COPD. Pharmacist’s Letter/Prescriber’s Letter. August 2013.
* NEW: Titropium/olodaterol (Stiolto)
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Current Inhaled Medications for COPD Cont’d
Medication Brand Usual Starting Dose Duration
Inhaled Corticosteroids
Budesonide Pulmicort Flexhaler 1-2 puffs bid 12 h
Fluticasone Flovent HFA 1-2 puffs bid 12 h
Beclomethasone QVAR 1-2 puffs bid 12 h
Combination Inhalers
Formoterol/Budesonide Symbicort 2 puffs bid 12 h
Fluticasone/Salmeterol Advair DiskusAdvair HFA
1 puff bid2 puffs bid
12 h
Fluticasone/Vilanterol Breo Ellipta 1 puff daily 24 h