T R E N D S I N C A R E O F T H E E L D E R L Y

M A Y 2 , 2 0 1 8

D R M A R Y J A C K S O N

New Ideas/New Drugs in COPD“Old Doc, New Tricks”

Relationships with commercial interests:

Grants/Research Support: None

Speakers Bureau/Honoraria: None

Consulting Fees: None

Other: None

I do not intend to make therapeutic recommendations for medications that have not received regulatory approval

(e.g. off label use)

Freeport Physicians’ Education Days

Declaration of Conflict of Interest

Old Doc, New TricksDr. Mary Jackson

3

DISCLOSURE OF COMMERCIAL SUPPORT

This educational event has received unrestricted educational grants from the following organizations:

Amgen CanadaAstra Zeneca Canada

Bayer HealthCare PharmaGSK Canada

Janssen CanadaMerck Canada

Novartis Pharmaceuticals CanadaNovo Nordisk Canada

Pfizer Canada

Potential for conflict(s) of interest: AstraZeneca, GSK, Merck and Novartis produce products

referable to this presentation

Old Doc, New Tricks

Dr. Mary Jackson

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Mitigating Potential Conflict of Interest:

Recommendations for drug therapy will be based on peer

reviewed journal articles and published guidelines

Old Doc, New Tricks

Dr. Mary Jackson

5

Goal: To review new inhalers/medications for COPD, their indications and where they fit into the current treatment pyramid

Objectives:1. Participants will understand when and how to use new

COPD meds2. Participants will understand where new medications fit

into the plan of care for COPD3. Participants will have an enhanced understanding of the

management of COPD

Old Doc, New TricksDr. Mary Jackson

Old “tricksters”….

Setting the stage…..

COPD is a costly, common problem

4th leading cause of death in the world

Gender gap in mortality has disappeared

13% of Canadians 35-79 are afflicted

Highest rate of hospital admissions amongst chronic illnesses in Canada

Setting the stage 2…

Diagnosis is often delayed

Spirometry is key to the diagnosis

Comprehensive management includes; smoking cessation, vaccination, education, action plans, inhaled medications, pulmonary rehabilitation, oxygen, surgery and palliative care

Goals of therapy: reduced dyspnea and reduce exacerbations

From CTS guidelines: Pharmacotherapy: an update 2017

Treatment of COPD on one page…

 

smgh.ca

A MEMBER OF THE ST. JOSEPH’S HEALTH SYSTEM

St. Mary’s General Hospital

911 Queen’s Blvd.

Kitchener, ON, Canada

N2M 1B2

Tel: 519.744.3311

Airway Clinic

Education Referral Form

*PLEASE FAX REFERRAL FORM TO 519-749-6816*

Please call the Airway Clinic at 519-749-6868 (option 1) if you have any questions or concerns

Patient Name: HCN#:

Date of Birth: Gender: □ Male □ Female

Parent Name (if applicable):

Address:

Phone (Home): (Work):

Physician/Nurse Practitioner: CPSO #:

Reason for Referral: If diagnosis unclear please refer the patient for spirometry or pulmonary

function testing using Airway Clinic Pulmonary Diagnostics Referral Form before referring for Education

□ Asthma Clinic - includes pre and post bronchodilator spirometry if appropriate and self- management

education

□ COPD Activation - 5 session education and exercise program, assessment done at SMGH, exercise

classes done at SMGH Cardiac Rehab site in Waterloo (Must include spirometry/PFT confirming

diagnosis with referral form)

□ COPD Self-management Education (only for those not appropriate for exercise program)

Please indicate reason patient is not able to complete exercise

□ Smoking Cessation Counseling - individual counseling, baseline spirometry for those at risk for

COPD)

Relevant Medical History and Current Medications: (please include previous spirometry or PFT

results)

Signature of Referring Provider: Date:

Provider Address:

Provider Phone number: Fax:

SMGH Airway Clinic Response:     Please notify your patient an appointment has been scheduled for:  Date:                   Time:          

New IdeasNew Drugs for Maintenance Therapy

Different COPD phenotypes

Severity: not just FEV1

Inhaled steroids: helpful and harmful

Magic of macrolides

Cell of the year: The

Eosinophil

Optimizing inhaler therapy in the era of choice: Cost, Compliance and Coordination

A few pearls….

COPD Phenotypes…

Concept of asthma/COPD overlap is not new….but has renewed interest

Important to recognize as the approach to inhaled medications in different in these individuals from COPD alone (?increased role for corticosteroids..)

ACOS = Asthma COPD Overlap Syndrome is the new buzzword

Source: Uptodate

ACOS: CTS definition

Required: 1. Diagnosis of COPD

2. History of asthma

3. Spirometry with persistent post BD fixed airflow obstruction. (FEV1/FVC < 70%)

Supportive: 1. BD improvement of 12% AND >200ml

2. Sputum eosinophilia

3. Blood eosinophilia (>300 ugL)

ACOS- “Old tricks”?

Assessing Severity/Goals of Therapy

How does the clinician choose inhaled therapies? lessen dyspnea, reduce exacerbations, improve exercise tolerance and quality of life?

Assess dyspnea: CAT score/MRC dyspnea score

Assess ability to do activities

Inquire about exacerbation frequency

New guidelines use degree of dyspnea and exacerbation frequency to determine therapy

Assessing severity: Not just FEV1……

Case 1: assessing severity: MRC Dyspnea Score

Case 1: Assessing severity: CAT Score

www.catestonline.org

8 questions

Self administered

Score 0-40

>30 very high

5 upper normal

Guidelines for Therapy COPD: 2017

Frequent exacerbators do poorly

FEV1 is inversely proportional to exacerbation risk

A history of exacerbations predicts the future risk

AECOPD= an acute worsening requiring additional therapy

To reduce exacerbations;

add LAMA (better than LABA)

add ICS- low dose, consider subsequent stepdown

add macrolide,(roflumilast)/refer to respirology!

Exacerbations of COLD: “Lung Attacks”

Inhaled Corticosteroids(ICS): Helpful

In ACOS patients

In patients with moderate dyspnea and frequent exacerbations

In patients with severe dyspnea and frequent exacerbations

Local Systemic

Dysphonia

Topical candidiasis

HPA axis fxn can be affected, but effect infrequent(>1000mgm FC-7% abn ACTH stimLung infection. Slight incrrisk of pneumoniaOcular- conflicting data about effect on IOP?Osteoporosis-slight incr # risk in PM women on for long periods (>9 yrs)Bruising

Corticosteroids: Harmful

Corticosteroids: Amelioration

Refine use for ACOS and C,D patients(sicker)

Use Low Dose in COLD

Consider step up and step down therapy

Avoid chronic systemic steroid(Prednisone)

Use spacer device

Rinsing!!

Be aware of bone risk/ocular risk

Magic of Macrolides

Renewed interest in chronic antibiotic use in severe, refractory COPD

Azithromycin thought to have anti-inflammatory properties

Shown to delay time to first exacerbation, reduce frequency of exacerbations

Macrolides: practicalities

Consider when puffers aren’t enough and patient has frequent exacerbations

250 mg Monday, Wednesday, Friday

Avoid in those with long QT

If having acute bacterial bronchitis, stop macrolide and use another drug

Try drug holiday > 1 year

New Cell of the Year: The Eosinophil?

Respirologists have their own biologics…

Agents targeting IgE and interleukins (omalizumab, mepolizumab, reslizumab) now being used in difficult to control asthma

Subset of COPD patients with peripheral eosinophilia…

Suggestion that high eospredict those who respond to GCS

Recent studies looking at these drugs in “eosinophilicCOPD”….stay tuned….

Jungle of new inhalers….

Individualize by

considering;

Cost

Compliance

Coordination

And remember:

“if it isn’t broken, don’t fix

it…”

Treatment aimed at symptoms/exacerbations

Short acting bronchodilators (SABA OR SAMA)

Drug Cost

Salbutamol generic 5.00

Bricanyl 8.35

Ipratroprium 20.00

Mild disease A: prn bronchodilator (exertion, URTIs, etc)

Quick fix for B,C,D

Guidelines for Therapy COPD: 2017

Long Acting Beta agonists (LABA)

Brand 30dCost ODB LUF

Serevent 56.00 132(asthma)

391(COPD)

Foradil 52.50 132 (asthma)

Onbrez 46.50 443 (COPD)

Striverdi (respimat) N/A

First line therapy for mild or moderate

COLD (A,B)

LABA…not Lada….

Long acting muscarinic antagonists (LAMA)

Brand Cost 30d ODB LUF

Spiriva(both devices)52.50 Y

Seebri 53.00 Y

Tudorza 53.00 Y

Incruse 50.00 Y

First line therapy for mild or

Moderate COLD (A,B)

LABA/LAMA Combinations

Brand Cost ODB LUF

Ultibro 80.40 459

Duaklir 60.00 459

Anoro 83.00 459

Inspiolto(respimat) 61.00 459

LABA/ICS Combinations

Brand Cost ODB LUF

Advair 125/250 97.43/138.51 330(asthma)

Symbicort 100/200 64.60/84.90 330(asthma)

Zenhale 100/200 93/112 330(asthma)

Breo (30d) 120.00 456(COPD)

Breo is once daily, others twice

Indication is for severe or very severe COLD

And frequent exacerbations

S/E of steroids: dysphonia, bruising, pneumonia? : balanced with

Reduced exacerbations, improved QOL, reduced dyspnea

ICS recommended for GOLD C and D patients

Inhaled Corticosteroids

Brand Cost(30d) ODB

Flovent (125mcg/250)$43/86 Y

Pulmicort(200mcg) $39 Y

Qvar (100mcg) $40 Y

Asmanex (400mcg) $74 Y

Triple combo….coming soon..

Coordination

Consider breath-activated vsdevice-activated

Patient with severely reduced flows may have difficulty with delivery from breath activated

Spacer device helps with coordination and deposition

Aerosol physics: A Design problem…..

Coordination

Consider removing small

capsules from blister packs

and arthritic hands…

Consider having the patient

demonstrate technique in the

office……

Approach to Rx

Diagnose: COPD or ACOS (spirometry pre and post BD)

SABA in ALL

Choose which longactingdrugs you need

Consider cost, coordination and compliance in choosing drug/device

Final words….

Assess the severity of disease (dyspnea, exacerbations…)

Consider asthma overlap as an additional therapeutic issue

Smoking cessation will have more impact on survival than any inhalers…

Inhalers are designed to reduce SYMPTOMS- and reduce FLARES

Keep it simple – don’t make the treatment worse than the problem

Drug plan?

Coordination and Compliance

Reassessment: Step up and step down…

The End