COPD: Enhancing Recognition and Improving Outcomes...VA study, 2003-2004. 93K new COPD diagnosis. – Just 36.7% with new diagnosis of COPD had spirometry 2y prior, to 6m after diagnosis

COPD: Enhancing Recognition and Improving Outcomes

MiCMRC Care ManagementEducational Webinar

MiCMRC Care Management Educational Webinar:Enhancing Recognition and Improving Outcomes

Expert Presenter:

Catherine A. Meldrum PhD RN MS CCRCUniversity of Michigan

Financial Disclosure

I do not any financial interests related to the content of this presentation.

Objectives Epidemiology: Burden Risk factors

Screening When and who to screen

Management: Is not just spirometry Advantages of the GOLD classification How to make it simple Pharmacologic therapies By GOLD group By phenotypes (CB. frequent exacerbation)

Non-pharmacologic therapies Comorbidities

Chronic obstructive pulmonary disease (COPD), a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.

Global Initiative for Chronic Obstructive Lung Disease (GOLD) ;a project initiated by the NHLBI and WHO define COPD 2016

Defining COPD




Non-pharmacologic therapies

0

10

20

30

40

50

60

70

1980 1985 1990 1995 2000

Men Women

COPD Mortality in the US 1980-2000Maybe not what you would suspect?

Year

Dea

ths

x 10

00

Mannino et al. MMWR Surveill Summ. 2002;51:1-16.

Percent Change in Age-Adjusted US Death Rates

3.0

2.5

2.0

1.5

1.0

0.5

01965-1998 1965-1998 1965-1998 1965-1998 1965-1998

CoronaryHeart

Disease

Stroke Other CVD

All Other Causes

-64%-59% -35% -7%

COPD

+163%

Global Initiative for Chronic Obstructive Lung Disease. NHLBI/WHO workshop report.2001. http://www.goldcopd.com/workshop/toc.html. Accessed: 14 November 2003.

COPD: Risk Factors

Tager et al. Am Rev Respir Dis. 1988;138:837-849; Holt. Thorax. 1987;42:241-249.

Established Probable PossibleCigarette

smoking Occupational

exposure

α1-Antitrypsin deficiency (genetic abnormality)

Air pollution

Exposure to primary and secondary smoke

Hyperactive airways

Alcohol

Poverty

Low birth weight

Childhood respiratory infections

Family history

Atopy

IgA deficiency

Blood type A

COPD: The Vicious Circle

Cooper. Med Sci Sports Exerc. 2001;33(7 suppl):S643-S646.

Chronic Pulmonary Disease

Physical Deconditioning

Physical Reconditioning

Decreased Exercise Capacity

Increased Exercise Capacity

Increased Breathlessness

Decreased Breathlessness

Immobility Pulmonary Rehabilitation

Increased VERequirement

Decreased VERequirement





COPD Diagnosis

Audience question

Which of the following screening tests is recommended by the USPHS Preventive Task Force:– Colonoscopy for detection of colon cancer– Mammogram for breast cancer detection– Chest CT for lung cancer detection– Neonatal tests for CF– Spirometry for COPD detection

Systematic Review of the Evidence: US Preventive Services Task Force

Conclusions:– No direct evidence indicates that screening

patients for COPD using spirometry improves long-term health outcomes.

– Screening for COPD using spirometry is likely to identify a predominance of patients with mild to moderate airflow obstruction who would not experience additional health benefits if labeled as having COPD.

Siu et al. JAMA 2016;315:1372-7.

Spirometry use

VA study, 2003-2004. 93K new COPD diagnosis.– Just 36.7% with new diagnosis of COPD had

spirometry 2y prior, to 6m after diagnosis.– Regional variation.

2002-2003 Ntl. Committee for Quality Assurance. 1.5M members, 5K new COPD.– Claims 2y prior to, to 6m after diagnosis.– Just 32% with new diagnosis of COPD had

spirometry. Lower in older patients.

Han MK. Chest 2007;132: 403Joo M. Chest 2008; 134: 38

Barriers to COPD diagnosisPessimistic view of the disease:

– Tobacco-related. Self-inflicted.– There is nothing than can be done for a COPD patient

who continues smoking.Barr et al. Am J Med 2005; 118: 1415e.

Perceived efficacy of spirometry and recommendations:– Conflicting recommendations about screening

spirometry.– Conflicting recommendations about treatment.

Salinas et. al. Int J COPD 2011; 6: 171.

Pathway to Diagnosing COPD

Global Initiative for Chronic Obstructive Lung Disease.. http://www.goldcopd.org. Accessed: 10 February 2017.

SYMPTOMSShortness of breath

Chronic coughSputum

RISK FACTORSHost factors

TobaccoOccupation

Indoor/outdoor pollution

SPIROMETRY: Required to establish diagnosis

Adapted from Fletcher et al. BMJ. 1977;1:1645-1648.

Disease must be detectable in an early stage: Lung Function Over Time

FEV 1

(%) R

elat

ive

to A

ge 2

5

Never smoked or notsusceptible to smoke

Stopped Smoking at 45 (Mild COPD)

Stopped smoking at 65 (Severe COPD)Death

Disability

Smoked regularly and susceptible to its effects

Age (Years)50 75250

Symptoms

0

20

50

60

100

80

40

Mannino et al. MMWR Morb Mortal Wkly Rep. 2002;51:1-16.

050

100150200250300350400450

Diagnosed with chronic bronchitis or emphysema

Airflow limitation (GOLD 1 or higher)

Rate

per

100

0 of

Pop

ulat

ion

25-44 45-54 55-64 65-74 >/=75Age (years)

Underdiagnosis of COPD in the United States

7.2%

14%

20.7%

22.9%

Effects of Smoking Cessation on Lung Function

Smoking cessation even at early stages of disease slows the decline of lung function

Smoking Cessation Slows Lung Function Decline in Mild COPD:

Lung Health Study at 11 YearsReproduced with permission from:Anthonisen et al. Am J Respir Crit Care Med. 2002;166:675-679; Calverley et al. Lancet.2003;362:1053-1061. BMJ Publishing Group.

2.02.12.22.32.42.52.62.72.82.9

0 1 2 3 4 5 6 7 8 9 10 11

FEV 1

(L)

Year

Sustained Quitters

Intermittent Quitters

Continuous Smokers





Goals for Treatment of Stable COPD

1. Assess airflow severity and monitor disease

2. Reduce symptoms and risk factors

3. Manage stable COPD through– Patient education– Pharmacologic management– Nonpharmacologic treatment

4. Manage exacerbations

5. Presence of comorbidities

GOLD Recommendations. Updated 2017. Available at: www.goldcopd.com. Accessed February 8, 2017.

Airflow Limitation Severity in COPD








COPD: Risk Factors

Tager et al. Am Rev Respir Dis. 1988;138:837-849; Holt. Thorax. 1987;42:241-249.

Established Probable PossibleCigarette

smoking Occupational

exposure

α1-Antitrypsin deficiency (genetic abnormality)

Air pollution

Exposure to primary and secondary smoke

Hyperactive airways

Alcohol

Poverty

Low birth weight

Childhood respiratory infections

Family history

Atopy

IgA deficiency

Blood type A

Smoking Cessation

First Line medication: buproprion, SR, varenicline, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine spray, nicotine patch

Second line agents: clonidine and nortriptyline

Counseling effective

Quit lines

What are the first-line medicationsRecommended in this Guideline update?

All seven of the FDA-approved medications for treatingtobacco use are recommended: bupropion SR, nicotine gum,

nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline. The clinician should consider the first-line medications shown to be more effective than the nicotine patch alone: 2 mg/day varenicline or the combination

of long-term nicotine patch use + ad libitum NRT (nicotine replacement therapy). Unfortunately, there are no well-

accepted algorithms to guide optimal selection among thefirst-line medications.

Treating Tobacco Use and DependenceClinical Practice Guideline 2008

US Department of Health & Human Services

www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf accessed Feb 22, 2009

Bornemann, Paul, et al. "Smoking cessation: what should you recommend?" Journal of Family Practice, Jan. 2016, p. 22+. Academic OneFile, Accessed 15 Feb. 2017.

Spirometry is key:

Required for diagnosis

Determine “severity”

Useful to decide treatment

Quaseem. Ann Intern Med 2011;155: 179

Airflow Limitation Severity in COPD

ABCD Assessment Tool

GOLD Guidelines (in English)

Ask two questions– Symptoms (Dyspnea)– Risk of exacerbation (h/o AE)

Put the answers together– Low or high symptoms (mMRC 2)– Low risk (AE <2)

Create groups (2x2 table)






5. Presence of comorbiditiesGOLD Recommendations. Updated 2017. Available at: www.goldcopd.com. Accessed February 8, 2017.

Achievable Outcomes of Therapy in COPD

Bronchodilators are effective in improving airflow and lung volume

Symptomatic patients with appropriate treatment can expect– Relief of dyspnea– Improvement of exercise tolerance– Improvement of quality of life– Decrease in exacerbations

Global Initiative for Chronic Obstructive Lung Disease. Executive Summary Updated 2017. Available at: http://www.goldcopd.com. Accessed February 11, 2017.

GOLD Guidelines OverviewGOLD Defined by: English

TranslationTreatment

A MMRC <2 Low symptomsLow risk

SABA or SAMA

B MMRC >= 2AE < 2

High symptomsHigh risk

LAMA or LABA

C MMRC <2AE > = 2

Low symptomsLow risk

ICS/LABA or LAMA

D MMRC >=2AE > = 2

High symptomsHigh risk

ICS/LABA and/or LAMA

Practical Implication of GOLD Groups

If patient has been admitted to a hospital– They are already high risk, regardless of

symptoms (C/D)– Needs ICS + LABA and/or LAMA– In addition to SABA

Pharmacologic therapy recommendations based on groups

Therapy

Pharmacologic therapy: BLABA vs. LAMA

AE COPD and related hospitalization: LAMA

Mortality and all-cause hospitalization: No difference

Symptoms and lung function: No difference

Group 1st line 2nd line

A SABA or SAMA

LABA or LAMASABA and SAMA

B LAMA or LABA

LAMA and LABA

ICS/LABA vs. LABA Mortality: No difference AE, QOL, symptoms:

ICS/LABAICS vs. LABA AE COPD and mortality:

Similar. Lung function: LABA QOL: ICS Pneumonia: ICS

Group 1st line 2nd lineA SABA or

SAMALABA or LAMASABA and SAMA

B LAMA or LABA

LAMA and LABA

C ICS/LABA or LABA

LAMA and LABA

Pharmacologic therapy: C

Pharmacologic therapy: D

Group 1st line 2nd line

C ICS/LABA or LABA

LAMA and LABA

D Same Same orICS/LABA and PD4I

LAMA vs. LABA in AE COPDLower AE frequency

LAMA plus ICS/LABA in COPDBetter lung function

Vogelmeier C. NEJM 2011; 364: 1093AaronSD. Ann intern Med 2007; 146: 545







Nonpharmacologic Treatments

Pulmonary Rehabilitation

Education & Self Management

Integrated Care Programs

Pulmonary Rehabilitation

Improves shortness of breath, health status and exercise tolerance

Reduces hospitalization among patients who have had a recent exacerbation (≤ 4 weeks from prior hospitalization)

Education & Self Management

Patient knowledge is important for behavior change though not sufficient to promote self-management interventions

Self management: – Improve outcomes in COPD– Improve health status– Reduces hospitalization– No impact on overall mortality

Integrated Care Programs

Evidence on this is divided

Meta-analysis of small trials demonstrated it may improve clinical outcomes but not mortality

One large multi-center study in primary care did not confirm this

Delivering integrated interventions by phone did not demonstrate a significant effect

Further research is needed in this area

Non-pharmacologic therapy recommendations based on groups

Groups Therapy A-D

– Smoking cessation– Physical activity– Flu and pneumococcal

vaccination

B-D– Add Pulmonary

Rehabilitation







AECOPD Consensus Definition

“A sustained worsening of the patient’s condition, from the stable state and beyond normal day-to-day variations, that is acute in onset and necessitates a change in regular medication in a patient with underlying COPD”

Rodriguez-Roisin. Chest. 2000;117:398S-401S.

AECOPD Outpatient Management Patient education

–Check inhalation technique–Consider use of spacer devicesBronchodilators

–SABA and/or ipratropium MDI with spacer or hand-held nebulizer as needed

–Consider adding long-acting bronchodilator if patient is not using one

Corticosteroids –Prednisone 30-40 mg orally/day for at least 5 days–Consider using an inhaled corticosteroid

Celli BR, et al. Eur Respir J. 2004;23:932-946.

Preventing Frequent Exacerbation

Albert RK. NEJM 2011;365: 689

Practical Implication of Frequent Exacerbation Phenotype

If patient is discharged with AE COPD– Should already be on antibiotics– Is at high risk of readmission, new AE– No need to initiate chronic macrolide at time of

discharge– Include in your diagnosis “this is a patient with

frequent exacerbation phenotype (2 or more/y)”– Consider or discuss exacerbation prevention

interventions

Roflumilast in frequent exacerbation*

0

0.5

1

1.5

2

2.5

All patients Infrequent exacerbators Frequent exacerbators

Mea

n ra

te o

f mod

erat

e or

sev

ere

exac

erba

tions

per

yea

r

Placebo Roflumilast

Δ = –16.9%Rate ratio 0.831

(95% CI 0.75, 0.92)p=0.0003

n=1537

*FREQUENT EXACERBATORS (≥2 MODERATE OR SEVERE EXACERBATIONS IN PREVIOUS YEAR)INFREQUENT EXACERBATORS (<2 MODERATE OR SEVERE EXACERBATIONS IN PREVIOUS YEAR)

n=1554 n=1137 n=1124 n=417 n=413

Δ = –16.5%Rate ratio 0.835

(95% CI 0.73, 0.95)p=0.0062

Δ = –22.3%Rate ratio 0.777

(95% CI 0.66, 0.91)p=0.0017

a POST-HOC ANALYSESBateman ED et al Eur Respir J 2011; 38:553-560

Roflumilast in CB phenotype

Rennard SI et al; Respir Res 2011; 12: 1

Practical Implication of Chronic Bronchitis Phenotype

Roflumilast: specific therapy for a COPD phenotype– CB with frequent exacerbation– Can be initiated in- or out-patient– Consider roflumilast for exacerbation prevention








Comorbidities

Cardiovascular disease

Skeletal muscle dysfunction

Metabolic syndrome

Osteoporosis

Depression

Anxiety

Lung cancer

OSA

Resources for COPD Informationwww.copdfoundation.org

Documents

COPD: Enhancing Recognition and Improving Outcomes...VA study, 2003-2004. 93K new COPD diagnosis. – Just 36.7% with new diagnosis of COPD had spirometry 2y prior, to 6m after diagnosis