copd guidelines sarah cowdell. why guidelines matter predicted to be the third leading cause of...

COPD GUIDELINES

Sarah Cowdell

WHY GUIDELINES MATTER

Predicted to be the third leading cause of death by 2030

Cause of over 30,000 deaths in the UK yearly

Chronically underdiagnosed – ( by up to 1/3 )

The cause of massive spend in healthcare resources (drugs, bed-days, primary care consultations, workdays lost, comorbidities, mortality.

Impact on sufferers and their carers

WHATS GOING ON • 2010 NICE update ( Gold

Guidance)• COPD STRATEGY• NICE QUALITY INDICATORS

• Oxygen suppliers reprocurement

• New HOOF /HOCF

• New Drugs

• Community COPD service

• Community referral pulmonary rehabilitation.

• ESD• Decomissioned OP

secondary care work

Wakefield and KirkleesCOPD Guidance

• Diagnosis of COPD• Management of Stable Disease• Treatment of Acute Exacerbations• Taken from the NICE (2004)2010 update

Definition Disease classified by airways obstruction which is not reversible, is usually progressive and does not vary from day today.

It will usually occur in smokers or ex smokers over the age of 50.

Main symptoms include dyspnoea, cough and sputum production.

• Airflow obstruction is defined as a reduction in FEV1/FVC ratio <0.7

• No longer necessary to have FEV1 <80% predicted for definition of airflow obstruction*

• If FEV1 is ≥ 80% a diagnosis of COPD should only be made in the presence of respiratory symptoms and/or reduced ratio.

• *post bronchodilator

Severity

Mild Reduced FEV1/FVC, Normal FEV1

Moderate FEV1 50-80%

Severe FEV1 30-49%

Very severe FEV1 <30%

FEV1 ≥ 50% FEV1 < 50%

SABA or SAMA as required*

LABA LAMA**Offer LAMA in

preference to regular SAMA four times a

day

LABA + ICS in a combination inhaler

Consider LABA + LAMA if ICS declined or not

tolerated

LAMA**Offer LAMA in

preference to regular SAMA four times a

day

LABA + ICS in a combination inhaler

Consider LABA + LAMA if ICS declined or not tolerated

LAMA + LABA + ICS

Inhaled therapy

Breathless and/or exercise limitation

Exacerbations or persistent breathlessness

Persistent exacerbations or breathlessness

Consider therapy

Offer therapy

Thorax February 2011; 66:93-96

Cost implicationsFometerol Turbohaler £23.75

Salmeterol MDI £27.80

Salmeterol Accuhaler £29.26

Symbicort Turbohaler £38.00

Seretide Accuhaler £40.92

Seretide MDI £59.58

Tiotropium Handihaler £34.87

Tiotropium Respimat £36.26

Other therapies• Carbocisteine

– Reduce exacerbations if chronic sputum production- £16.03

• Theophylline– May improve breathless, may enhance action

of ICS- Approx £5.00

• Montelukast– Not recommended for COPD

Summary• Bronchodilators improve symptoms• No clear benefit of 1 agent over another• “Adding on” bronchodilators improves

symptoms further• Adding on inhaled corticosteroids has a small additional benefit

• Importance of the inhaler device

Other stuff n.b presence of haemoptysis in a newly diagnosed or otherwise stable pt require urgent fast track referral

• Chest x-ray• FBC/U&E• BMI• MRC score/Ex

tolerance• Smoking status• Infection frequency• Vaccination

• PLAN• Treatment level• Disease Info• SMOKING CESSATION• Review frequency• Self-management• Pulmonary

rehabilitation

CAT COPD assessment test• The CAT provides a reliable measure of the impact of COPD on a patients health status• Score 5 – (upper limit of normal in healthy non-smokers)• Score <10 (low)

» Smoking cessation» Annual flu vaccination» Reduce exposure to exacerbation risk factors» Therapy as warranted by further clinical assessment

• Score 10-20 (medium)» Review maintenance therapy» Referral for pulmonary rehabilitation» Best approaches to minimizing and managing exacerbations» Review aggravating factors – is the patient still smoking?

• Score >20 (high)» Additional pharmacological treatments» Referral to pulmonary rehabilitation» Ensuring best approaches to minimising and managing exacerbations

• Score >30 (very high)» In addition to the guidance for patients with low and medium impact CAT

scores consider:» Referral to specialist care

Pulmonary Rehabilitation• Offer to all patients who consider

themselves functionally disabled by COPD• Make available to all appropriate people,

including those recently hospitalised from an acute exacerbation [2010]

• Hold at times that suit patients and in buildings with good access

Pulmonary rehabilitation• Paddock Jubilee Centre• Twice weekly for 8 weeks• Structured exercise programme• Education component• MRC score of ≥ 3• Transport cannot be provided

12 months before PR

12 months

after PR

Change

Admissions 9 7 -22%

Length of stay (days)

8.5 5.1 -40%

Bed days 76.5 35.7 -53%

Managing exacerbations• The frequency of exacerbations should be reduced by

appropriate use of inhaled corticosteroids and bronchodilators

• Give self management advice on responding promptly to symptoms of exacerbation.

• Start appropriate treatment with oral steroids and antibiotics

• Use of hospital-at-home or assisted-discharge schemes

• Use of NIV as indicated

EXACERBATIONS

• A SUSTAINED WORSENING (+ 24 hours) OF SYMPTOMS REQUIRING A CHANGE IN TREATMENT

• CHANGE IN SPUTUM COLOUR• INCREASE IN COUGH • CHANGE IN VOLUME OF SPUTUM ( LESS OR MORE)• INCREASED BREATHLESSNESS OR TAKING LONGER THAN USUAL

TO RECOVER FROM USUAL ACTIVITY

Amoxicillin 500mg TDS 7 daysPrednisolone 30mg OD 7 days

Reducing mortality

Exacerbationsand mortality

300

400

500

600

Seebri 44 µg o.d. Placebo Seebri 44 µg o.d. Placebo

Exe

rcis

e en

du

ran

ce t

ime

(s)

Δ (95% CI): 88.9(44.7,133.2) seconds, p<0.001

Day 1 Day 21

Δ (95% CI): 43.1(10.9,75.4) seconds, p<0.001

GLOW3: Seebri significantly improved exercise tolerance on Days 1 and 21 against placebo

0

Beeh KM et al. International Journal of COPD, 2012;7 5013-513 SBH12-C038 Date of Prep October 2012

What’s New?• INDERCATEROL = ONBREZ • GLYCOPYRRONIUM BROMIDE = SEEBREE• ACLIDINIUM =

Indercaterol - once daily long acting beta2 agonist

Dry powder device

GLYCOPYRRONIUM BROMIDE Once daily long acting anti muscarinic

MUSCARINIC

Aclidinium• Twice daily long acting antimuscarinic• Novel inhaler device

Roflumilast• Anti-inflammatory, reduces exacerbations• Not approved by NICE• £37.71

Placebo Roflumilast

Moderate/severe exacerbations

1.37 1.14

(ARR -17%)

Use of systemic steroids and/or antibiotics

1.35 1.13

(ARR -16%)

The future?

• Anti-inflammatories?– Exacerbation reduction– Disease progression?

• More combinations of current molecules– Once daily triple therapy in 1 inhaler?

http://ckw.wdpct.nhs.uk/documents/long-term-conditions/