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 Kirklees COPD 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%
Inhaled therapy
SABA or SAMA as required*
Breathless and/or exercise limitation
Exacerbations or persistent breathlessness
FEV1 â&#x2030;Ľ 50%
LABA
FEV1 < 50%
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 Persistent exacerbations or breathlessness
Offer therapy Consider therapy
Thorax February 2011; 66:93-96
Cost implications Fometerol Turbohaler Salmeterol MDI Salmeterol Accuhaler Symbicort Turbohaler Seretide Accuhaler Seretide MDI Tiotropium Handihaler Tiotropium Respimat
£23.75 £27.80 £29.26 £38.00 £40.92 £59.58 £34.87 £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
» » » »
Review maintenance therapy Referral for pulmonary rehabilitation Best approaches to minimizing and managing exacerbations Review aggravating factors – is the patient still smoking?
» » »
Additional pharmacological treatments Referral to pulmonary rehabilitation Ensuring best approaches to minimising and managing exacerbations
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In addition to the guidance for patients with low and medium impact CAT scores consider: Referral to specialist care
Score 10-20 (medium)
Score >20 (high)
Score >30 (very high)
»
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 days Prednisolone 30mg OD 7 days
Reducing mortality
Exacerbations and mortality
GLOW3: Seebri significantly improved exercise tolerance on Days 1 and 21 against placebo Δ (95% CI): 88.9 (44.7,133.2) seconds, p<0.001
Δ (95% CI): 43.1 (10.9,75.4) seconds, p<0.001
600
500
() tm a u d n is rc e x E
400
300 0 Seebri 44 µg o.d. Placebo Day 1 SBH12-C038 Date of Prep October 2012
Seebri 44 µg o.d. Placebo Day 21
Beeh KM et al. International Journal of COPD, 2012;7 5013-513
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 â&#x20AC;˘ Twice daily long acting antimuscarinic â&#x20AC;˘ Novel inhaler device
Roflumilast • Anti-inflammatory, reduces exacerbations • Not approved by NICE • £37.71 Moderate/severe exacerbations Use of systemic steroids and/or antibiotics
Placebo 1.37
Roflumilast 1.14 (ARR -17%)
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-termconditions/