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Nottinghamshire COPD and Asthma Guidelines
Dr Esther GladmanGP Prescribing Lead, Medicines
Management Nottingham City CCGFeb 2012
Where to find & other resources
• Google: Nottinghamshire Area Prescribing Committee
– Medicines Traffic Light Classification List– Shared Care Protocols– Clinical Guidelines – Formularies– Policies and Prescribing Position Statements
• E-healthscope• www.patient.co.uk• www.prodigy.nhs.uk (was CKS)
e.g. from prodigy : What simple measures can I advise to manage breathlessness for people with end-stage COPD?• Advise the person on the following simple measures to manage
breathlessness.– Sitting in front of a fan or open window (or using a hand-held fan).– Positioning
• For example, advise the person to sit or stand leaning forward (for example onto a table or the back of a chair) and supporting their weight with their arms and upper body.
– Pursed-lip breathing• Advise the person to inhale through the nose and then exhale slowly, for 4–
6 seconds, through pursed lips.
• Other simple measures, not specific to chronic obstructive pulmonary disease (COPD) but recommended in the section on Simple measures to help dyspnoea in the PRODIGY topic on Palliative cancer care - dyspnoea, may be useful for people with COPD.
Nottinghamshire COPD GuidelineKey points
• Most effective interventions• Be aware other conditions• Effective/cost effective prescribing• Steroid dose, pneumonia & adverse • Be aware side effects and adverse effects
of meds• Where can you make a difference?
Most Effective Interventions
• 1. Stopping smoking is the only treatment that slows the progression of COPDand is the most cost effective treatment in COPD. NNT 5 –to prevent death at age 70
• Motivational questioning, cost cigs & inhalers, Allen Carr, anxiety, dopamine,worsening of symptoms, dementia
Most Effective Interventions: 2. Pulmonary Rehabilitation
• MRC dyspnoea score 3, 4, 5 • or recent admission
“more breathless than contemporaries when walking or gets breathless on exertion & needs to rest”– NNT 2 to improve exercise tolerance by a clinically
useful amount– NNT 4 to stop readmission over 6/12 if given early
after an exacerbation
Most Effective Interventions3. Self Management Plans
• NNT 10 to reduce admission in low risk patients
• NNT 3 to reduce admission in high risk patients (1 previous admission or LTOT or previous use of Prednisolone)
• NNT 5 for patient held “emergency supply pack” (prednisolone +/- antibiotic) to reduce admission
Beware diagnosis• >40 years old• Smoker or ex-smoker, non-smoking spouse of
smoker or dusty occupation• Spirometry FEV1 < 80% predicted and post
bronchodilator FEV1/FVC ratio < 70% and typical symptoms
• NB FEV1 – an increase of >400ml after bronchodilator suggests asthma not COPD
• Consider CXR/FBC, ECG for alternative diagnoses or red flag symptoms such as haemoptysis
Be aware: are symptoms in accord with severity of COPD?
– FEV1 Rapid decline? e.g. >200ml in 3 years, exacerbations/Excess sputum
– Re-assess for co-morbidity, treatment adherence, inhaler technique
• Consider bronchiectasis • check sputum for unusual organisms/Acid &
Alcohol Fast bacilli• ? Ca CXR,FBC,ECG
• NB 25 % will have IHD/ cardiac failure
Effective/cost effective prescribing
• Stop smoking• Optimise inhaler technique (e.g. spacers
with MDIs)• Consider stopping new treatment if
patient feels no improvement (4 weeks)– longer may be needed for a reduction
in exacerbations• Consider stepping down/swopping
Effective/cost effective prescribing
• LABA vs LAMA – there is no significant difference re: reduction in exacerbation or hospitalisation rates.
Effective/cost effective prescribing
• There is no combination MDI licensed for COPD
• However if patient preference: –Fostair 100/6 (2 puffs BD £29.32) –or Seretide 125 + spacer (2puffs BD, £35)
can be considered, which gives similar ICS dose to Accuhaler 500.
• NB Seretide 250 MDI is not recommended
Adverse effects of steroid
• High dose ICS (ie fluticasone 1000 mcg = Seretide 250) increases the risk of pneumonia, NNH = 47 ie. Beware those with frequent exacerbations
• Other steroid effects - Diab/thrush/cataracts• Osteoporosis prophylaxis for patients having
4 courses of oral steroid within 12 months
Be aware side effects and adverse effects of meds
• Use tiotropium Spiriva Handihaler® (18 mcg/day) not Spiriva Respimat® (mist device)All patients must be advised not to exceed the maximum daily dose
• All anticholinergics have some cardiovascular effect
• Fometerol and beta agonists also have effect
NBs• Mucolytic only if troublesome phlegm:
carbocisteine 750mg TDS (£24.60) can be trialled for 4 weeks. – Stop if no effect. – Drop to maintenance dose: 750mg BD if effective.– Consider using in winter months only.– Mucolytics do not prevent exacerbations
• Consider theophylline 3rd line: Uniphyllin 200mg BD (£2.94) care with elderly & concomitant medications see BNF. Theophylline levels?
NNT=33
NBs
• 25% will have co-morbidity e.g. IHD/cardiac failure. Beta blockers can be used in COPD
• Dose of emergency supply pack?
Actions• Flu & pneumococcal vaccination• Inhaler use/Medication /step • Stop smoking advice /refer New Leaf• Patient info/empowerment• MRC dyspnoea score 3, 4 or 5/functional
disability refer for pulmonary rehabilitation• Self management plan and anticipatory
prescription pack• Weight/diet/exercise. Little & often leaflets
• Oxygen Sat ≤92% - refer to chest clinic /oxygen assessment service
• Palliative Care Planning If end-stage COPD/cor pulmonale
Nottinghamshire Adult Asthma Treatment Summary
• Micro break & shake
Nottinghamshire Asthma GuidelineKey points
• Step up and down• Use LABA and ICS in a combination inhaler• Be aware of inhaler equivalent steroid doses• Step 3a is addition of LABA not increase ICS too• Twitchiness of asthma• Same steroid risks as for COPD• Pros & cons of SMART• Theophylline levels/interactions
Step Consider stepping up if:
1. Using SABA 3 times a week or more
2. Symptoms 3 or > times x week
3. An exacerbation in the last 2 years
4. Waking due to symptoms one night a week
• Ensure adherence and inhaler technique
Consider stepping down if :
Asthma control has been good for 3 months on current therapy
N.B. Steroid dose reductions should be slow as patients deteriorate at different rates. Reduce by 25-50% & monitor
Appropriate spacer/ Other devices? Peak flow meter?
Step 3anb add LABA only
Step 3b & c
Step 3 alternative
SMARTPros: opener & reliever, inc dose steroid when need it Cons: device, symptoms, side effects
Step 4 asthma nb this is where use of Seretide 250 MDI is appropriate
nb
• Oral steroid - sometimes higher dose & shorter course than COPD
• Same steroid risks as for COPD• Written Self-Management
Plan/lifestyle/house dust mite/patient beliefs/info
• Co-morbidity
Key points summary
• Step up and down• Always give LABA and ICS in combination
inhaler (unlike COPD)
• Step 3a is addition of LABA not increase ICS too
• Be aware potency of ICS Inhaler and equivalent steroid doses