Chronic Obstructive Lung Disease: GOLD Guidelines

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Chronic Obstructive Lung DiseaseGOLD Guidelines

• Baylor College of Medicine
• Combined Med-Peds Program
• Anoop Agrawal, M.D.

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COPD - Definition

• Global Obstructive Lung Disease Guidelines (GOLD)
  first published in 2001
• Disease state characterized by airflow
  limitation that is no longer fully reversible and
  is usually progressive... This results in a
  chronic inflammatory response in the walls and
  lumen of the airways.
• GOLD guidelines were recently updated in 2006

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COPD - Prevalence

• Affects 15 million Americans
• Fourth leading cause of mortality (100,000/year)
• Only major health problem for which mortality has
  been increasing for past 20 years
• Results in 500,000 hospitalizations/year
• Second leading cause of missed work days
• There are numerous published guidelines - GOLD
  being the most prominent (www.goldcopd.com)

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COPD - Risk Factors

• Hereditary - Alpha-1 Antitrypsin Deficiency
• Environmental
• Cigarette Smoking
• What percent of smokers will develop COPD?
• 15-20 (1 in 5) - this implies a genetic
  predisposition to developing COPD tends to
  cluster in families
• Occupational exposures to dust, chemicals

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COPD - Diagnosis

• Symptoms
• chronic cough - intermittent, nonproductive
• cough with sputum production, smokers cough
• dyspnea on exertion, usually progressive and
  indolent
• Spirometry
• Should spirometry screening be performed on the
  general population?
• No, but in those with higher risk - i.e. all
  current and former smokers over the age of 40
  years with any of the above symptoms of disease

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The Importance of Screening for COPD

• The Rule of 50s
• 50 of COPD patients are undiagnosed (or
  approximately 12 million patients in U.S.)
• COPD is evident by age 50
• At time of diagnosis, FEV1 is lt50 predicted
• 50 5-year survival rate

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Raising COPD Awareness
November is National COPD Awareness Month
World COPD Day took place on November 19th, 2008.
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COPD Staging

• Based upon the GOLD Guidelines - 2006 update
• Classified into 4 stages
• Staging is based primarily upon FEV1
• FEV1 lt 80
• FEV1FVC lt 70
• The lower the FEV1 the more severe the disease
  classification.

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GOLD Guidelines for Therapy
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COPD Management and Therapies

• Vaccination - pneumococcal and influenza
• Regular Assessment of lung function - annually
• Cessation of tobacco use
• Drug Therapy
• short acting vs. long acting bronchodilators
• inhaled vs. oral corticosteroids

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COPD - Management of Stable Disease

• Smoking cessation rate of FEV1 deterioration
  will slow to near normal (20 ml /yr vs. 65 ml /yr
  for active smokers) if patient stops smoking

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COPD - Drug Therapy

• Therapy recommendations based on their effect on
  FEV1.
• First Line therapy
• Beta agonists - short and long acting
• Anticholinergics - short and long acting
• Second Line therapy
• Steroids - inhaled vs. oral
• Supplemental therapies

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Beta agonists

• Mechanism of Action - bronchodilate by
  stimulating Beta-2 receptors
• Studies show that COPD patients do not develop
  tolerance to short acting or long acting beta
  agonists
• Asthmatics tend to develop tolerance to short
  acting agonists
• Can Salmeterol be used as monotherapy?

Drug Albuterol Salmeterol
Onset 1 to 3 min 20 min
Duration 4 to 6 hrs 12 hrs
B2B1 selectivity 13751 85,0001
YES, salmeterol monotherapy had adverse outcomes
in asthma study, note copd.
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Anticholinergics

• Mechanism of action- bronchodilation by
  decreasing airway smooth muscle tone
• Also reduces sputum production
• Combination of an anticholinergic B2-agonist
  produces greater and more sustained rise in FEV1
  than either drug alone.

Drug Ipratropium Tiotropium
Onset 20 min ?
Duration 4 to 8 hrs 24 hrs
Selectivity All Muscarinic M1 and M3gt M2
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Tiotropium (Spiriva)

• Studies show that once daily tiotropium has
  resulted in a lasting increase in FEV1 out to one
  year.
• 174 ml above baseline in good short-term
  responders
• 56 ml increase in poor short-term responders

Special delivery device.
Tashkin,D. Chest 2003 May 1231441-9
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Inhaled Corticosteroids (ICS)

• Have not been shown to slow the progression of
  disease or provide long term benefit
• ISOLDE trial - patients with FEV1 of 50
  predicted value had a 25 reduction of
  exacerbations
• Combination with salmeterol more effective in
  reducing exacerbations than either drug alone
• Unfortunately, recently published trial failed to
  demonstrate statistically significant reduction
  in mortality with salmeterol/fluticasone combo.
• Use of ICS increases likelihood of pneumonia.

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New COPD Treatment Data

• INSPIRE - study published in Jan 2008
• compared salmeterol/fluticasone head to head with
  tiotropium
• No difference in exacerbation rate although more
  in tiotropium group had higher drop out rate.
• More patients in salmeterol/fluticasone developed
  pneumonia.

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Oral Corticosteroids

• They have no proven benefit in stable COPD
• Oral steroids are useful for acute exacerbations
• What is the recommended duration of therapy?
• Maximum benefit obtained during first 2 weeks of
  therapy.

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Supplemental Therapies

• Supplemental oxygen for hypoxemia (worn for more
  than 15 hrs/day) has been shown to reduce
  moratality
• What are the qualification parameters for oxygen
  therapy?
• PaO2 of 55mmHg or less, or pulse oximetry of 88
  or less
• Pulmonary Rehabilitation
• Lung reduction and lung transplantation surgeries

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GOLD Guidelines for Therapy
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Summary

• Early diagnosis, disease prevention, smoking
  cessation and vaccination are important.
• Initiate bronchodilator therapy early in disease
  course, combination of albuterol with ipratropium
  most effective
• Inhaled corticosteroids may be useful in patients
  with severe disease or with objective responses
  on spirometry.
• Will likely see inflammatory modulators (TNF-a)
  in the future

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