Update on Chronic Obstructive Pulmonary Disease (COPD ... · PDF file•COPD Hospital Re‐admissions w/in 30 days: 19.6% ... * Agents Marked in Red was released since the last GOLD

Update on Chronic Obstructive Pulmonary Disease

(COPD): Going for GOLDLeigh Anne Hylton Gravatt, PharmD,

BCPSAssistant Professor

VCU School of Pharmacy

Financial Disclosure

I have no relevant finances to disclose.

Learning Objectives• Review the epidemiology and the financial impact

associated with Chronic Obstructive Pulmonary Disorder (COPD).

• Discuss the revised diagnostic criteria and classification system for COPD.

• Compare and contrast the literature supporting the new agents for COPD with the established therapies and define their role in the treatment of COPD.

• Design a treatment algorithm for patients with COPD using the GOLD guidelines and discuss considerations for cost, ease of administration, and long‐term outcomes for these therapies.

Chronic Obstructive Pulmonary Disease (COPD)

• Common, preventable and treatable disease that is characterized by:– Persistent respiratory symptoms– Airflow limitation

• Airway or alveolar abnormalities that are caused by significant exposure to noxious particles or gases

• Common Sx:– Dyspnea, cough and/or sputum production– Often under‐reported

• May have periods of acute worsening of respiratory symptoms, called exacerbations

Global Initiative For Chronic Obstructive Lung Disease 2017 Reportwww.goldcopd.org

COPD: What is the Impact?

• 4th leading cause of death in the world

• 3 million died in 2012– 6% of deaths globally

• US: 12.7 million

Lancet 2012; 380(9859): 2095‐128.PLoS Med 2006;3(11):e442. http://www.who.int/mediacentre/factsheets/fs310/en/

The Economics of COPD

• US– Direct cost: $32 billion– Indirect cost: $20.4 billion

• Those admitted to the hospital in respiratory failure due to COPD ~ 50% will die within 2 years

CEOR 2013;5:235‐45.Chest. 2002;121:1441‐8.N Engl J Med 2009;360:1418‐1428.

COPD Hospital Re‐admissions

• COPD Hospital Re‐admissions w/in 30 days: 19.6%– Estimate expense: $17 billion/year

• Correlation between COPD readmission rates and readmission rates for other conditions– CHF, AMI, CAP, CVA

• Section 3025 ACA Section 1886q : The Hospital Readmissions Reduction Program (HRRP)– CMS to decrease payments for those with excessive readmissions starting October 1st 2012

– In 2014, Re‐admissions for Acute exacerbation of COPD was added to this list

CEOR 2013;5:235‐45.Chest. 2002;121:1441‐8.N Engl J Med 2009;360:1418‐1428.Am J Respir Crit Care Med. 2017. doi:10.1164/rccm.201609‐1944OC.

COPD: Pathophysiology

Airways‐ Chronic inflammation, increased goblet cells,

mucus gland hyperplasia, fibrosis and narrowing of small airways and airway

collapse

Airways‐ Chronic inflammation, increased goblet cells,

mucus gland hyperplasia, fibrosis and narrowing of small airways and airway

collapse

Lung Parencyhema‐Destruction of respiratory

bronchioles, alveolar ducts, alveolar sacs and

alveoli

Lung Parencyhema‐Destruction of respiratory

bronchioles, alveolar ducts, alveolar sacs and

alveoli

Pulmonary Vasculature‐ Intimal hyperplasia,

smooth muscle hyperatrophy/hyperplasia,

chronic hypoxic vasoconstriction of small

pulmonary arteries

Pulmonary Vasculature‐ Intimal hyperplasia,

smooth muscle hyperatrophy/hyperplasia,

chronic hypoxic vasoconstriction of small

pulmonary arteries

Global Initiative For Chronic Obstructive Lung Disease 2017 Reportwww.goldcopd.orgLancet 2012; 379:1341‐51.https://www.drugs.com/health‐guide/images/205041.jpg

COPD Pathophysiology

• Smoking and pollutants

• Host Factors

EtiologyEtiology

•Impaired lung growthAccelerated decline

•Lung InjuryLung and Systemic Inflammation

PathobiologyPathobiology• Small airway disorders or abnormalitiesEmphysema

• Systemic effects

PathologyPathology

• Persistent airflow limitation

Airflow limitationAirflow limitation


COPD: Risk Factors

Childhood Resp. Infections

Age and Gender

Lung Growth and

Development

Socioeconomic Status Asthma


Diagnosis of COPD

SymptomsSymptoms Risk FactorsRisk

Factors SpirometrySpirometry

‐ Shortness of Breath‐ Chronic Cough‐ Sputum

‐ Host Factors‐ Tobacco‐ Occupation‐ Indoor/Outdoor Pollutants

‐ Required for diagnosis‐ Post‐bronchdilator

FEV1/FVC<0.7


Key Indicators for COPD Consider for ANYONE > 40 Years Old

Dyspnea ‐ Worse over time‐ Worse with exercise‐ Persistent

Chronic Cough ‐ Intermittent‐ May be unproductive‐ Recurrent wheeze

Chronic Sputum Production

Recurrent Lower Respiratory Tract Infections

History of Risk Factors

‐ Genetic, congenital or developmental‐ Tobacco use‐ Smoke from home cooking or heating fuels‐ Occupational dust, vapors, fumes, gases or other devices

FH or COPD ORChildhood Factors

‐ Low birth weight‐ Childhood respiratory infections


Classification of Airflow Limitation

Grade Post‐Bronchodilator FEV1 % Predicted

GOLD 1‐ Mild ≥ 80%

GOLD 2‐ Moderate 50‐81%

GOLD 3‐ Severe 30‐49%

GOLD 4‐ Very Severe < 30%


Symptom and Airflow AssessmentModified British Medical Research Council (mMRC) Questionnaire COPD Assessment Test (CAT)


Revised Classification System

CC DD

AA BB


mMRC 0‐1 mMRC ≥ 2

CAT < 10 CAT ≥ 10

Symptoms

Exacerbation History

≥ 2 or ≥ 1 leading to hospital admission

0‐1 (Not leading to Hospital Admission)

SpirometryAssessment was removed

What’s your Letter Grade?

• Pt. with an FEV1< 45%• Pt. only has trouble with SOB when walking quickly or uphill

• She has had 1 COPD exacerbation in the last year that was treated as an outpatient

Grade Post‐Bronchodilator FEV1

Gold 1 FEV1≥ 80% predicted

Gold 2 50% ≤ FEV1 < 80% predicted


Gold 4 < 30% FEV1 predictedGlobal Initiative For Chronic Obstructive Lung Disease 2017 Reportwww.goldcopd.org

What’s your Letter Grade?

• Based on the patient characteristics, how would you classify this patient?– A. Category A– B. Category B– C. Category C– D. Category D

Revised Classification System

CC DD

AA BB



CAT < 10 CAT ≥ 10

Symptoms




Grade 3, Group A

GOLD Levels of EvidenceEvidence Category Sources of Evidence

A Randomized controlled trials (RCT); Rich body of evidence

B Randomized controlled trials (RCT) with important limitations to the body of evidence

C Nonrandomized trials; Observational studies

D Panel consensus judgment


Non‐Pharmacologic Treatment

Smoking Cessation

• Pharmacotherapy and Nicotine Replacement Therapies help to increase long‐term smoking abstinence rates

• E‐cigarette use is controversial

Vaccinations

• Annual Influenza vaccination (Evidence B)• 23‐valent pneumococcal polysaccharide vaccine (PPSV23): Decreased incidence of CAP in COPD patients < 65 YO w/ an FEV1< 40% (Evidence B)

• Adults ≥ 65YO, 13‐valent conjugated pneumococcal vaccine (PCV13) is effective in reducing bacteremia and serious pneumococcal disease (Evidence B)

Pulmonary Rehabilitation

• Pumonary rehabilitation improves dyspnea, health status, and exercise tolerance in stable patients (Evidence A)


Non‐Pharmacologic Treatment

Education/Self‐Management

• Education alone has not shown to be effective (Evidence C)• Self‐management interventions w/ communication w/ a health care professional improves health status and decreases hospitalizations and ER visits (Evidence B)

Palliative Care

• Opiates, neuromuscular electrical stimulation (NMES), oxygen, and fans blowing air onto the face can relieve breathlessness (Evidence C)

• In malnourished patients, nutritional supplementation may improve respiratory muscle strength and overall health status (Evidence B)

• Fatigue can be improved by self‐management education, pulmonary rehabilitation, nutritional support and mind‐body interventions (Evidence B)


MANAGEMENT OF STABLE COPD

Therapeutic Classes• Bronchodilators

– Short Acting Beta‐Agonist (SABA)– Long Acting Beta‐Agonist (LABA)– Short Acting Anticholinergics (muscarinics) (SAMA)– Long Acting Anticholinergics (muscarinics) (LAMA)– Combination products– Methylxanthines

• Corticosteroids– Inhaled – Oral– Combination Inhaled Corticosteroid + LABA

• Phosphodiasterase 4 Inhibitors• Antibiotics

Definitions: Types of Inhalers

MDI: Metered Dose Inhaler

‐ Chemical Propellant‐ Must coordinate

breath with inhalation‐ 8.9% lung depositions (mean dose delivered)

MDI: Metered Dose Inhaler

‐ Chemical Propellant‐ Must coordinate

breath with inhalation‐ 8.9% lung depositions (mean dose delivered)

DPI: Dry Powder Inhaler

‐ No chemical propellant‐ Requires a deep, fast breath‐ 28.5% lung deposition (mean dose delivered)

DPI: Dry Powder Inhaler

‐ No chemical propellant‐ Requires a deep, fast breath‐ 28.5% lung deposition (mean dose delivered)

SMI: Soft Mist Inhaler (Respimat®)‐ Slowly released‐ Long Lasting‐ Fine Droplets‐ 51.6% lung deposition (mean dose delivered)

SMI: Soft Mist Inhaler (Respimat®)‐ Slowly released‐ Long Lasting‐ Fine Droplets‐ 51.6% lung deposition (mean dose delivered)

Anderson P International Journal of COPD 2006; 1(3): 251‐259Pitcairn G et al. J Aerosol Med 2005; 18(3): 264‐272

Beta2‐Agonist BronchodilatorsDrug Inhaler (mcg) Nebulizer

solution(mg/ml)

Oral Vials for Injection (mg)

Duration of Action

Short Acting (SABA)

Levalbuterol(Xopenex®)

45‐90 MDI 0.1, 0.21, 0.25, 0.42

6‐8

Salbutamol (albuterol)(Proventil HFA®, Ventolin HFA®)

90, 100, 200 MDI &DPI

1, 2, 2.5, 5 2, 4, 5mg pill; 8mg XR,

0.024% syrup

0.1, 0.5 mg 4‐6, 12 (XR)


Beta2‐Agonist BronchodilatorsDrug Inhaler (mcg) Nebulizer solution

(mg/ml)Duration of Action

Long Acting (LABA)

Arformoterol(Brovana®)

0.0075 12

Formoterol(Performist®)

4.5‐9 DPI 0.01 12

Indacaterol(Arcapta Neohaler®)

75‐300 DPI 24

Olodaterol*(Striverdi Respimat®)

2.5, 5 SMI 24

Salmeterol(Serevent Diskus®)

25‐50 MDI &DPI 12

* Agents Marked in Red was released since the last GOLD update in 2011Global Initiative For Chronic Obstructive Lung Disease 2017 Reportwww.goldcopd.org

Anticholinergic BronchodilatorsDrug Inhaler (mcg) Nebulizer solution


Short Acting (SAMA)

Ipratropium bromide(Atrovent®)

20‐40 MDI 0.2 6‐8

Long Acting (LAMA)

Aclidinium bromide*(Tudorza Pressair®)

400 DPI & MDI 0.0075 12

Glycopyrronium bromide*(Seebri Breezhaler®)

15.6 & 50 DPI 12‐24

Tiotropium(Spiriva Handihaler and Respimat®)

18 DPI, 2.5&5 SMI

24

Umeclidinium*(Incruse Ellipta®)

62.5 DPI 24


New Bronchodilators in GOLDInhaler MOA Year Dose Product

Olodaterol (StriverdiRespimat®)

LABA 2014 2 inhalations once daily

Aclidiniumbromide(TudorzaPressair®)

LAMA 2012 1 inhalation BID

http://docs.boehringer‐ingelheim.com/Prescribing%20Information/PIs/Striverdi%20Respimat/striverdi.pdfhttps://www.tudorza.com/


Glycopyrronium bromide(SeebriBreezhaler®)

LAMA 2015 1 capsule inhaled BID

Umeclidinium (Incruse Ellipta®)

LAMA 2014 1 inhalation once daily

https://www.gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Incruse_Ellipta/pdf/INCRUSE‐ELLIPTA‐PI‐PIL.PDF


Tiotropium (Spiriva Respimat®)

LAMA 2014 2 inhalations once daily

https://www.gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Incruse_Ellipta/pdf/INCRUSE‐ELLIPTA‐PI‐PIL.PDF

GOLD: Bronchodilators in COPD• Inhaled bronchodilators in COPD are central to symptom

management and commonly given on a regular basis to prevent or reduce symptoms (Evidence A)

• Regular and as‐ needed use of SABA or SAMA improves FEV1and symptoms (Evidence A)

• LABAs and LAMAs significantly improve lung function, dyspnea, health status and reduce exacerbation rates (Evidence A)

• LAMAs have a greater effect on exacerbation reduction compared with LABAs (Evidence A) and decrease hospitalizations (Evidence B)


GOLD: Bronchodilators in COPD• Tiotropium improves the effectiveness of pulmonary rehabilitation in increasing exercise performance (Evidence B)

• LABAs and LAMAs are preferred over SA agents except for patients with only occasional dyspnea (Evidence A)

• Patients may be started on single LABA or LAMA or LABA+LAMA. In patients with persistent dyspnea on one bronchodilator treatment, treatment should then be escalated to dual therapy (Evidence A)


Combination ProductsDrug Inhaler (mcg) Nebulizer solution


Short Acting Beta2 Agonist + Anticholinergic

Salbutamol/ipratropium(Combivent Respimat®, Duoneb®)

100/20 SMI, 75/15 MDI 0.5, 2.5mg in 3ml 6‐8

Long Acting Beta2‐Agonist + Anticholinergic

Formoterol/glycopyrronium *(Bevespi Aerosphere®)

9.6/14.4 DPI 12

Indacaterol/glycopyrronium*(Utibron Neohaler®)

27.5/15.6 & 110/50 DPI

12‐24

Vilanterol/umeclidinium*(Anoro Ellipta®)

25/62.5 DPI 24

Olodaterol/tiotropium*(Stiolta Respimat®)

5/5 SMI 24


GOLD: Combination Bronchodilators

• Combination treatment with a LABA and LAMA increases FEV1 and reduces symptoms compared to monotherapy (Evidence A)

• Combination treatment with a LABA and LAMA reduces exacerbations compared to monotherapy (Evidence B) or ICS/LABA (Evidence B)


LABA/LAMA vs. MonotherapyTrial Farne HA, Cates CJ. Long‐acting beta2‐agonist in addition to

tiotropium vs. either tiotropium or long‐acting beta2‐agonist alone for COPD

Methods Cochrane Database Review10 studies10.894 patients

Intervention Tiotropium +LABA vs. Tiotropium vs. LABA

Results ‐ Small improvement in HR‐QOL and FEV1 with combination therapy

‐ Adding Tiotropium to a LABA decreased exacerbations, but not vice versa

‐ No effect on hospitalizations

Cochrane Database Syst Rev 2015; 10(10):CD008989.

LAMA/LABA Combinations in GOLDInhaler MOA Year Dose Product

Formoterol/glycopyrronium(BevespiAerosphere®)

LAMA/LABA 2016 2 inhalations BID

Indacaterol/glycopyrronium(UtibronNeohaler®)

LAMA/LABA 2015 1 capsule inhaled once BID

https://www.pharma.us.novartis.com/utibron‐neohaler

LAMA/LABA Combinations in GOLDInhaler MOA Year Dose Product

Vilanterol/umeclidinium(Anoro Ellipta®)

LAMA/LABA 2013 1 inhalation once daily

Olodaterol/tiotropium(StioltaRespimat®)

LAMA/LABA 2015 2 inhalations once daily

http://www.anoro.com/about/index.html?bing=e_&rotation=71700000009621674&banner=58700000826471212&kw=8776596690&cc=099FF0995E7A&pid=43700008776596690

https://www.stiolto.com/what‐is‐stiolto‐respimat?sc=STOACQBRABANBING160602&utm_source=bing&utm_medium=cpc&utm_term=Stiolto_respimat&utm_campaign=Branded_‐_Stiolto_Respimat_[Exact]&gclid=CIn4752rgtMCFYqiNwod6‐sCCA&gclsrc=ds

Combination ProductsDrug Inhaler (mcg) Duration of Action

Long Acting Beta2‐Agonist + Corticosteroids

Formoterol/budesonide(Symbicort®)

4.5/160 MDI, 4/5/80 MDI, 9/320 DPI, 9/160 DPI

12

Formoterol/mometasone(Dulera®)

10/200, 10/400 MDI 12‐24

Salmeterol/fluticasonse(Advair HFA®, Advair Diskus®)

5/100, 5/250, 5/500 DPI; 21/45, 21/115, 21/230 MDI

24

Vilanterol/fluticaone furoate*(Breo Ellipta®)

25/100 DPI 24

* Agents Marked in Red was released since the last GOLD update in 2011


ICS/LABA Combinations in GOLDInhaler MOA Year Dose Product

Vilanterol/fluticaone furoate(Breo Ellipta®)

ICS/LABA 2013 1 inhalation twice daily

http://www.mybreo.com/?bing=e_&rotation=71700000020120045&banner=58700002134115964&kw=17657748589&cc=9A7DDB62954F&pid=43700008776747173&gclid=CPD1i_GtgtMCFYGONwodHRYPDw&gclsrc=ds

Fluticasone Furoate‐VilanterolTrial Vestbo J, Leather D, Diar Bakerly N, et al. Effectiveness of

Fluticasone Furoate and vilanterol for COPD in Clinical Practice

Methods Prospective, 12 month, open‐label, parallel randomized multi‐center trial

Intervention Fluticasone furoate‐Vilanterol (100/25 mcg) inhaled once daily vs. Usual Care* Allowed to continue LAMA use

Primary Outcome Rates of moderate‐severe exacerbations in those who had at least 1 exacerbation in the last year

BaselineCharacteristics

N Engl J Med 2016; 575(13):1253‐60.

Fluticasone Furoate‐Vilanterol

N Engl J Med 2016; 575(13):1253‐60.

Fluticasone Furoate‐Vilanterol

N Engl J Med 2016; 575(13):1253‐60.

GOLD: ICS and LABAs in COPD• ICS + LABA is more effective than the individual components in improving lung function and health status and reducing exacerbations in patients with exacerbations and with moderate to severe disease(Evidence A)

• Regular treatment with ICS increases the risk of pneumonia, especially those with severe disease (Evidence A)

• Triple inhaled therapy ICS/LAMA/LABA improves lung function, symptoms and health status (Evidence A) and reduces exacerbations (Evidence B) compared to ICS/LABA or LAMA monotherapy


Triple TherapyYear Trial # Interventions Results

2008 Sigh D, Brooks J, Haga G, et al.

41 ‐Salmeterol/fluticasonepropionate (50/500) BID + tiotropium (18 mcg) once daily‐ Individual Components

‐ Triple therapy led to great improvement in spirometry data vs. the individual components

2012 Jung KS, Park HY, Park SY, et al.

657 ‐Salmeterol/fluticasonepropionate (50/250) BID+ tiotropium once daily(18 mcg) ‐ Tiotropium (18 mcg) once daily

‐ Triple therapy provided greater spirometry changes andimproved QOL score vs. monotherapy

2015 Frith PA, Thompson PJ, Ratnavadivel R, et al.

773 ‐ Salmeterol/fluticasonepropionate (50/500) BID + EITHERTiotropium 18 mcg daily, Glycopyrronium 50 mcg daily, or Placebo

‐ Triple therapy including Glycopyrronium was found to be non‐inferior to that with Tiotropium

ICS and Risk of Pneumonia

• Highest Risk– Current smokers– BMI< 25 kg/m2

– Age ≥ 55 years old– History of prior exacerbations or pneumonia– Poor MRC dyspnea grade – Severe airflow limitations

Global Initiative For Chronic Obstructive Lung Disease 2017 Reportwww.goldcopd.orgAnnals of the American Thoracic Society 2015; 12(1)27‐34

GOLD: Corticosteroids and PDE 4 inhibitors in COPD

• Long term use of oral glucocorticoids has numerous side effects(Evidence A) with no evidence of benefit (Evidence C)

• In patients with chronic bronchitis, severe to very severe COPD and a history of exacerbations, A PDE‐4 inhibitor improves lung function and reduces moderate to severe exacerbations (Evidence A) and also dose this in patient who are on fixed doses LABA/ICS combinations (Evidence B)


Other AgentsDrug Oral Vials for Injection (mg) Duration of Action

Methylxanthines

Aminophylline 105 mg/ml 250, 500 mg Variable, up to 24 hours

Theophylline SR 100‐600mg pill 250, 400, 500 mg Variable, up to 24 hours

Phophodiesterase‐4 Inhibitors

Roflumilast 500 mcg pill


Antibiotics Use in COPD

• Regimens:– Azithromycin: 250mg PO daily or 500mg TIW– Erythromycin 500mg PO BID

• Mainly reserved for individuals with severe disease and frequent exacerbations

• Has been shown to increase the incidence of bacterial resistance and impaired hearing test

• No data beyond 1 year of useGlobal Initiative For Chronic Obstructive Lung Disease 2017 Reportwww.goldcopd.orgAm J Respir Crit Care Med 2008; 178(11):1139‐47.The Lancet Respiratory medicine 2014;2(5):361‐8.N Engl J Med 2011; 365(8):689‐98.

Role of Antibiotics: Meta‐AnalysisTrial Ni W, Shao X, Cai X, et al. Prophylactic Use of macrolide

antibiotics for prevention of COPD exacerbations: A Meta‐Analysis

Methods 9 studies1,666 patients

Interventions Azithromycin, Erythromycin and Clarithromycin at varying doses and frequencies

PlOS one 2015; 10(3):e0121257

Role of Antibiotics: Meta‐Analysis

PlOS one 2015; 10(3):e0121257

GOLD: Other Medication Therapies• Antibiotics

– Long term azithromycin and erythromycin therapy reduces exacerbations over one year (Evidence A)

– Treatment with azithromycin is associated with an increased incidence of bacterial resistance (Evidence A) and hearing test impairment (Evidence B)

• Statins– Statin therapy is not recommended for prevention of exacerbations (Evidence A)

• Theophylline– Theophylline is not recommended unless other long‐term bronchodilators are unavailable or unaffordable (Evidence B)


GOLD: Oxygen Therapy in COPD

• Long‐term administration of oxygen increases survival in patients with severe chronic resting arterial hypoxemia (Evidence A)

• In those with stable COPD and with exercised induced desaturations, long term oxygen does not lengthen time to death or first hospitalization or provide sustained benefits long term (Evidence A)


Treatment Algorithm

Group C‐ Start with a LAMA

‐ If sx persist, switch to EITHER LAMA+LABA OR

LABA+ICS

Group C‐ Start with a LAMA

‐ If sx persist, switch to EITHER LAMA+LABA OR

LABA+ICS

Group D‐ LABA + LAMA

‐ If sx persist, switch to ICS/LABA

‐ If sx persist, consider ICS/LABA + LAMA

Group D‐ LABA + LAMA

‐ If sx persist, switch to ICS/LABA

‐ If sx persist, consider ICS/LABA + LAMA

Group A‐ Bronchodilator

(SABA, SAMA, LABA, or LAMA)

‐ If sx persistent switch to another alternative

class

Group A‐ Bronchodilator

(SABA, SAMA, LABA, or LAMA)

‐ If sx persistent switch to another alternative

class

Group B‐ LABA or LAMA

‐ If sx persists, change to LABA + LAMA

Group B‐ LABA or LAMA

‐ If sx persists, change to LABA + LAMA


If FEV1< 50% and has chronic bronchitis consider starting roflumilast

Consider macrolide (in former smokers

Patient Case

• Pt. with an FEV1< 45%• Pt. only has trouble with SOB when walking quickly or uphill

• She has had 1 COPD exacerbation in the last year that was treated as an outpatient

Grade Post‐Bronchodilator FEV1

Gold 1 FEV1≥ 80% predicted



Gold 4 < 30% FEV1 predictedGlobal Initiative For Chronic Obstructive Lung Disease 2017 Reportwww.goldcopd.org

Patient Case

CC DD

AA BB



CAT < 10 CAT ≥ 10

Symptoms




Grade 3, Group A

Patient Case

• Based on the following classification, which of the following therapies would be the BEST initial therapy to begin in this patient?– A. ICS alone– B. LABA alone– C. LAMA alone– D. ICS/LABA

Monitoring

• Measurements (at least yearly)– Spirometry– 6‐minute walking distance– Measure oxygenation at rest

• Symptoms– Cough, sputum production, breathlessness, fatigue, activity limitation and sleep disturbances

• Exacerbations• Imaging• Smoking status


Monitoring

• Pharmacotherapy– Assess inhaler technique– Review dosages – Assess adherence– Side effects

Thorax 2009; 64:939‐43.

Cost Considerations

Patient Case

• The patient returns in 8 months following 2 exacerbations, 1 which resulted in a hospitalization. She states that she has had increased cough and sputum production. Which would be the next BEST therapy option?– A. Change to an ICS/LABA therapy– B. Change to a LABA/LAMA therapy– C. Initiate Azithromycin 250mg PO daily– D. Change to ICS/LABA + LAMA

Questions

Documents

Update on Chronic Obstructive Pulmonary Disease (COPD ... · PDF file•COPD Hospital Re‐admissions w/in 30 days: 19.6% ... * Agents Marked in Red was released since the last GOLD