Chronic Obstructive Pulmonary Disease

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Chronic Obstructive Pulmonary Disease
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What is COPD?NICE Clinical Guideline 12, Feb 2004

• Disease characterised by airflow obstruction,
  which is usually progressive, not fully
  reversible, and does not change markedly over
  several months.
• Airflow obstruction is due to a combination of
  airway and parenchymal damage and is associated
  with chronic inflammation, which differs from
  that seen in asthma.

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So, what can we do for people with COPD?

• Early diagnosis contentious
• NICE recommendation
• (smoker gt35 years, presenting with symptoms)
• Smoking cessation most important
• NICE recommendation
• Pulmonary rehabilitation important
• Cochrane Review
• NICE recommendation
• Optimal drug management (including managing
  exacerbations)
• See later

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Symptoms NICE Clinical Guideline 12, Feb 2004

• Diagnosis relies on clinical judgement based on a
  combination of
• history
• physical examination
• confirmation of the presence of airflow
  obstruction using spirometry

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Assessment of severity of airflow obstruction
NICE Clinical Guideline 12, Feb 2004
Severity FEV1
Mild airflow obstruction 50 80 predicted
Moderate airflow obstruction 30 49 predicted
Severe airflow obstruction lt 30 predicted
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Stop smoking NICE Clinical Guideline 12, Feb
2004National Knowledge Week for COPD 2008.
Available from http//www.library.nhs.uk/respirat
ory/ViewResource.aspx?resID278340tabID290catID
5880

• Approximately 80 of COPD caused by smoking
• Smoking cessation is the only intervention that
  reduces decline in FEV1
• Best way to reduce incidence of COPD is to reduce
  prevalence of smoking
• campaigns aimed at smokers need to emphasise link
  between smoking and COPD
• Encouraging patients with COPD to stop smoking is
  one of the most important components of their
  management
• All COPD patients still smoking, regardless of
  age should be encouraged to stop, and offered
  help to do so, at every opportunity

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Management of stable COPDNICE Clinical Guideline
12, Feb 2004
Breathlessness and exercise limitation
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What about the role oflong-acting
bronchodilatorsin COPD?
NICE Clinical Guideline 12, Feb 2004
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LABA (Salmeterol or Formoterol) Appleton. Cochrane 2006 Shukla VK. CCOHTA 2006 LABA (Salmeterol or Formoterol) Appleton. Cochrane 2006 Shukla VK. CCOHTA 2006 Tiotropium Barr RG. Cochrane 2005. Rodrigo GJ. Pulmon Pharmacol Ther 2007
Efficacy vs. placebo ? exacerbations, possibly ? hospitalisations More evidence for salmeterol vs. placebo ? exacerbations, possibly ? hospitalisations More evidence for salmeterol vs. placebo or ipratropium ? exacerbations, ? hospitalisations
Safety Most common immediate adverse effect of ß2 agonists is tremor, but high doses can reduce potassium, cause abnormal heart rhythm and reduce arterial oxygen tension MHRA review ongoing in asthma and COPD Most common immediate adverse effect of ß2 agonists is tremor, but high doses can reduce potassium, cause abnormal heart rhythm and reduce arterial oxygen tension MHRA review ongoing in asthma and COPD Most common adverse effect is dry mouth (more common than with ipratropium). Others include constipation, candidiasis, sinusitis and pharyngitis FDA review ongoing
Patient factors Patient preference Previous use Ease of use etc. Patient preference Previous use Ease of use etc. Patient preference Previous use Ease of use etc.
Cost Drug Tariff April 2008 Foradil 29.23 (60-dose) Oxis Turbohaler 12 24.80 (60-dose) Atimos modulite 31.28 (100-dose) Serevent Evohaler 29.26 (120 dose) Serevent Accuhaler 29.26 (60 dose) Spiriva Handihaler 37.62 (30 dose) re-fill 34.40 Spiriva Respimat 37.62 (60 dose) Spiriva Handihaler 37.62 (30 dose) re-fill 34.40 Spiriva Respimat 37.62 (60 dose)
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When should ICS be used?NICE Clinical Guideline
12, Feb 2004
Breathlessness and exercise limitation
Frequent exacerbations
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We need to weigh up the balance of risks and
benefits of prescribing ICS in COPD
Possible RISKS oral candidiasis hoarseness osteopo
rosis pneumonia
BENEFITS ? exacerbations possibly better QoL
Details are given on subsequent slides
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The TORCH StudyCalverley PMA, et al. N Engl J
Med 200735677589

• Comparing combination with salmeterol alone over
  three years
• NNT to prevent one moderate to severe
  exacerbation in one year is 8 (combination vs.
  salmeterol alone)
• NNH for one case of pneumonia in one year is 33
  (combination vs. salmeterol alone)

Salmeterol 50mcg only Salmeterol fluticasone (50/500mcg) P value
All-cause mortality (primary endpoint) 13.5 12.6 0.48 NS
Moderate/severe exacerbations 0.97/yr 0.85/yr 0.002
Exacerbations requiring hospitalisation 0.16/yr 0.16/yr 0.79 NS
Pneumonia 13.3 (0.04/yr) 19.6 (0.07/yr) lt0.001
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Oral mucolytic agents and/or influenza vaccination
NICE Clinical Guideline 12, Feb 2004
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Oxygen therapyNICE Clinical Guideline 12, Feb
2004

• The need for oxygen therapy should be assessed
  in
• all patients with severe airflow obstruction
  (FEV1 less than 30 predicted)
• patients with cyanosis, polycythaemia, peripheral
  oedema, raised jugular venous pressure, oxygen
  saturations less than or equal to 92 breathing
  air.
• Assessment should also be considered in patients
  with moderate airflow obstruction (FEV1 3049
  predicted).