trend of copd management
DESCRIPTION
แนวทางการรักษา COPD update 2011TRANSCRIPT
Trend of COPD management
รศ. นพ. วัชรา บุญสวัสด์ิ M.D., Ph.D.ประธานเครือขายคลินิคโรคหืดและปอดอุดก้ันเรื้อรังแบบงาย
ภาควิชาอายุรศาสตร คณะแพทยศาสตรมหาวิทยาลัยขอนแกน
ó COPD guideline
ó Changing concept in COPD treatment
ó Easy COPD clinic
Contents
2
3
4
Definition of COPD
1 211
5
3 48
6 7
910
Asthma
COPD
Airflowobstruction
EmphysemaChronicbronchitis
Reversible FEV1 Δ>15%
Irreversible FEV1 Δ <15%
5
Definition of COPD
ó COPD is a disease state characterized by airflow limitation that is not fully reversible.
ó The airflow limitation is usually both progressive and associated with an abnormal inflammatoryresponse of the lungs to noxious particles or gases.
6
FEV1
Force Expiratory Volume in 1 secondFVC
Force Vital Capacity
Post Bronchodilator FEV1 /FVC < 70 %
การตรวจสมรรถภาพปอด (spirometry)
7
8
9
Systemic effect of COPD
ó Systemic inflammation
ó Weight loss
ó Skeletal muscle dysfunction
10
Traditional view of COPD progression
Age (year)
FEV1
% o
f val
ue a
t age
25
yr
100
75
50
25
5025 75
Death
Disability
Adapted from:Fletcher C,et al.Br Med J.1977;1:1645-1648
Nonsmokers20-30 ml/year
COPD60 mL/year
symptoms
11
Stage II: Moderate 50% < FEV1 < 80% predicted
Stage III: Severe 30% < FEV1 < 50% predicted
Stage IV: Very Severe FEV1 < 30% predicted
Stage I: Mild FEV1 > 80% predicted
COPD
Airflow obstruction
Death
Air trapping
exacerbation
Reduced activity
Exercise limitation Deconditionin
g
Systemic effect of COPD•Weight loss•Skeletal muscle dysfunction
12
N Engl J Med 2004;350:1005-12.
BODE index
13
เปาหมายของการรักษา
ó ปองกันหรือชะลอการดําเนินโรคó บรรเทาอาการ โดยเฉพาะอาการหอบเหนื่อยó ทําให exercise tolerance ดีขึ้นó ทําใหคุณภาพชีวิตดีขึ้นó ปองกันและรักษาภาวะอาการกําเริบó ปองกันและรักษาภาวะแทรกซอนó ลดอัตราการเสียชีวิต
14
Treatment
ó Retard the progression of airflow obstruction
ó Minimizing airflow obstruction
ó Prevent complication
ó Optimizing functional capacity
15
Treatment
ó Retard the progression of airflow obstruction
ó Minimizing airflow obstruction
ó Prevent complication
ó Optimizing functional capacity
16
Anthonisen NR, JAMA,1994;2721497-150517
uropean espiratory ocietysstudyon hronic bstructive
ulmonary isease EUROSCOP)
18
Pauwels R. N Engl J Med 1999;340:1948-53.
Placebo
budesonide
Effect of inhaled Triamcinolone on the decline of pulmonary function in COPD
Lung Health Study. N Eng J Med 2000;343:1902-9
n=1116
None of the existing medications for COPD have been shown to modify the long-term decline in lung function that is the hallmark of this disease (Evidence A).
Therefore, pharmacotherapy for COPD is used to decrease symptoms and/or complications.
Treatment
ó Retard the progression of airflow obstruction
ó Minimizing airflow obstruction
ó Prevent complication
ó Optimizing functional capacity
Bronchodilators
1. Anticholinergics
2. B2 agonist
3. Theophylline
Corticosteroidsó Oraló Inhaled
Pharmacotherapy
22
Management of Stable COPD
Pharmacotherapy: Bronchodilators
§ Bronchodilator medications are central to the symptomatic management of COPD (Evidence A). They are given on an as-needed basis or on a regular basis to prevent or reduce symptoms and exacerbations.
§ The principal bronchodilator treatments are ß2- agonists, anticholinergics, and methylxanthines used singly or in combination (Evidence A).
§ Regular treatment with long-acting bronchodilators is more effective and convenient than treatment with short-acting bronchodilators (Evidence A).
Management of Stable COPD
Pharmacotherapy: Glucocorticosteroids
§Pro
§Con
25
uropean espiratoryocietysstudyon hronic
bstructive ulmonaryisease EUROSCOP)
Pauwels R. N Engl J Med 1999;340:1948-53.
Placebo
budesonide
26
27
28
Sin DD. AJRCCM 2001;164:580-58429
Sin DD. AJRCCM 2001;164:580-584
Inhaled corticosteroids and the risk of readmission and mortality
Thorax 2005;60:992–997.
D D Sin,
31
2.5
1.9
1.2
1.71.4
1.2
0
0.5
1
1.5
2
2.5
3
<1.25 1.25-1.54 >1.54
FEV1
Exac
erba
tions
per
yea
r
PlaceboFluticasone
ISOLDE. BMJ 2000;320:1297-130332
Short acting bronchodilator as needed
Regular bronchodilator treatmentinhaled corticosteroids
Oxygen therapy
Regular bronchodilator treatmentConsider inhaled corticosteroids
Regular bronchodilator treatment
FEV1>80%
FEV1 30-50%
FEV1 50-80%
FEV1 <30%
33
Short acting bronchodilator as needed
Regular bronchodilator treatmentinhaled corticosteroids
Oxygen therapy
Regular bronchodilator treatmentConsider inhaled corticosteroids
Regular bronchodilator treatment
FEV1>80%
FEV1 30-50%
FEV1 50-80%
FEV1 <30%
LABAICS
LABAICS
Oxygen therapy
34
Short acting bronchodilator as needed
ICS
Intermittent
Moderate persistent
Mild persistent
Severe persistent
LABAICS
LABAICS
prednisolone
35
Treatment
ó Retard the progression of airflow obstruction
ó Minimizing airflow obstruction
ó Prevent complication
ó Optimizing functional capacity
36
Treatment
ó Retard the progression of airflow obstruction
ó Minimizing airflow obstruction
ó Prevent complication
ó Optimizing functional capacity
37
Management of Stable COPD
Non-Pharmacologic Treatments
§ Rehabilitation: All COPD patients benefit from exercise training programs, improving with respect to both exercise tolerance and symptoms of dyspnea and fatigue (Evidence A).
§ Oxygen Therapy: The long-term administration of oxygen (> 15 hours per day) to patients with chronic respiratory failure has been shown to increase survival (Evidence A).
50/100 50/250 50/500
Seretide Diskus (Salmeterol +Fluticasone)
199939
What is Symbicort®?
Two strengths: • Symbicort® Turbuhaler® 160/4.5 µg• Symbicort® Turbuhaler® 80/4.5 µg
budesonide and formoterolin a single inhaler
40
41
Study designRun-in Randomisation
–0.5 0 1 2 3 Months 6 9 12
Clinic visits 1–8
Treatment
(Symbicort® Turbuhaler® ) bid
1 2 3 4 5 6 7 8
Terbutaline as reliever for all patients
ORAL PRED +FORM
Symbicort Turbuhaler 160/4.5 µg delivers the same amount of budesonide and formoterol as the corresponding Turbuhaler monoproducts
(Pulmicort® Turbuhaler®) 400 µg bid
(Oxis® Turbuhaler®) 9 µg bid
Placebo
42
43
Time to first exacerbation
44
*1.4
1.6
1.91.8
*p<0.05 vs placebop=0.015 Symbicort vs formoterol
Symbicort reduces severe exacerbationsMean no. of severe
exacerbations/patient/year
0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
Symbicort Budesonide Formoterol Placebo
45
Mean no. of days on oralsteroids/patient/year
p=0.022 Symbicort vs budesonidep=0.007 Symbicort vs formoterol
Symbicort reduces days on oral steroids
***p<0.001 vs placebo
11.08
9.699.06
***6.52
0
2
4
6
8
10
12
PlaceboFormoterolBudesonideSymbicort
46
47
Management of Stable COPD
Pharmacotherapy: Glucocorticosteroids
§ The addition of regular treatment with inhaledglucocorticosteroids to bronchodilator treatment is appropriate for symptomatic COPD patients with an FEV1 < 50% predicted (Stage III: Severe COPD and Stage IV: Very Severe COPD) and repeated exacerbations (Evidence A).
§ An inhaled glucocorticosteroid combined with a long-acting ß2-agonist is more effective than the individual components (Evidence A).
48
TOwards a Revolution in COPD Health – the TORCH trial
SFC 50/500 µg bd (N=1533)
TORCH: study design
SAL 50 µg bd (N=1521)
Placebo (N= 1524)3-year study duration
2 week run-in
FP 500 µg bd (N=1534)
Vestbo et al. Eur Respir J 2004; Calverley et al. NEJM 2007
TORCH: main objectivesPrimary objective
– The effect of SFC 50/500 µg vs placebo on all-cause mortality over 3 years in patients with moderate-to-severe COPD
Secondary objectives
– The effect of SFC 50/500 µg on the rate of moderate and severe exacerbations
– The effect of SFC 50/500 µg on health status (SGRQ)
Vestbo et al. Eur Respir J 2004Calverley et al. NEJM 2007SGRQ = St. George’s Respiratory Questionnaire
Vertical bars are standard errors
15241533
14641487
13991426
12931339
Numberalive
02468
1012141618
0 12 24 36 48 60 72 84 96 108 120 132 144 156Time to death (weeks)
Probability of death (%)
SFC 12.6%Placebo 15.2%
HR 0.825, p=0.05217.5% risk reduction
2.6% absolute reduction
Calverley et al. NEJM 200752
Rate of moderate and severe exacerbations over three years
*p < 0.001 vs placebo; †p = 0.002 vs SALM; ‡p = 0.024 vs FP
Mean number of exacerbations/year
1.13
0.97* 0.93*0.85*†‡
25% reduction
0
0.2
0.4
0.6
0.8
1
1.2
Placebo SALM FP SFC
Treatment
Calverley et al. NEJM 2007
1. Jenkins C et al. Poster (227) presented at ERS 2007.
SFC: impact of exacerbation history (TORCH)1
Exacerbation history: impact of SFC % reduction
No recalled exacerbations 19
1 exacerbation in previous year 26
≥2 exacerbations in previous year 31
• In patients with a history of more frequent exacerbations, there were trends to higher rates overall, and a greater effect of treatment
• Reductions in exacerbation rates associated with treatment are not dependent on a history of frequent exacerbations, and the benefits of SFC on exacerbations are still seen in patients who had no history of an exacerbation in the previous 12 months
SGRQ total score
–5–4–3–2–1
0123
0 24 48 72 96 120 156
Adjusted mean change SGRQ total score (units)
Time (weeks)
Placebo
SALM*FP†
*p = 0.057 vs placebo; †p < 0.001 vs placebo; ††p < 0.001 vs placebo, SALM and FP; vertical bars are standard errors
Number ofsubjects
1149114811551133
854906942941
781844848873
726807807814
675723751773
635701686731
569634629681
SFC††
Calverley et al. NEJM 2007
Post-bronchodilator FEV1Adjusted mean change FEV1 (mL)
0 24 48 72 96 120 156Time (weeks)
–150
–100
–50
0
50
100
Placebo SALM FP
**
*†
SFC
1524152115341533
1248131713461375
Number ofsubjects
1128121812301281
1049112711571180
979105410781139
906101210061073
819934908975
*p < 0.001 vs placebo; †p < 0.001 vs SALM and FPCalverley et al. NEJM 2007
SFC slows the rate of decline of lung function over 3 years (TORCH)
*p=0.003 vs placebo, **p<0.001
Note: this was a post hoc analysis
-50
-60
0
-20
-30
-40
-10
-55
Placebo
-42*
Sal
-42**
FP
-39**
SFC
Treatment arm
Adj
uste
d ra
te o
f dec
line
(ml/y
r)
-30
Non-COPD patient
TORCH study1. Celli BR et al. Am J Respir Crit Care Med 2008; 178: 332–338.57
58Jenkins. Respir Res 2009: 59
59
Jenkins. Respir Res 2009: 59
60
Jenkins. Respir Res 2009: 59
61
Summary of efficacy resultsSFC improved survival in COPD
This was supported by
– Significantly fewer exacerbations compared with components or placebo
– Significantly fewer hospitalisations compared with placebo
– Significant improvements in health status superior to components and placebo
– Significant improvements in lung function superior to components and placebo
1. Calverley et al. NEJM 20072. Jones et al. Chest 2006
None of the existing medications for COPD have been shown to modify the long-term decline in lung function that is the hallmark of this disease (Evidence A).
Therefore, pharmacotherapy for COPD is used to decrease symptoms and/or complications.
63
Definition of COPD: GOLD2006
• COPD is a preventable and treatabledisease with some significant extrapulmonary effects that may contribute to the severity in individual patients.
• Its pulmonary component is characterized by airflow limitation that is not fully reversible.
• The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.
64
COPD treatment in practice
ó 62 year oldó หอบเหน่ือยมา 1ปó สูบบุหรี่ 1 ซองมา40 ป
ó PE : wheezing both lung
ó Dx –COPD
65
66
67
Asthma
Episodic respiratory symptomsVariable airflow obstruction
occurring spontaneously, with treatment or after provocation
COPD
Incompletely reversible airflow obstruction
Overlap syndrome
Asthma and COPD—that is, symptoms ofincreased variability of airflow and
incompletely reversible airflow obstruction
•Asthma with chronic bronchitis•Chronic obstructive bronchitis•Asthma with permanent obstruction •COPD with a reversible component
Asthma vs COPD
69
Thoracic Society of Thailand:COPD Guidelines
70
Spirometry is not widely used in Thailand
71
Can we use Peak Flow meter to monitor COPD?
72
Easy COPD Clinic
73
ó สูบบุหรี่ Pack-year= จํานวนบุหรี่ท่ีสูบในแตละวัน X ระยะเวลา(ป)ó 20ó ไอเรื้อรัง ó เหน่ือยงายó มีว้ีด
CXR
PEFR <80%
Diagnosis COPD
74
75
การประเมินโรค
COPD
Airflow obstruction
Death
Air trapping
exacerbation
Reduced activity
Exercise limitation Deconditionin
g
Systemic effect of COPD•Weight loss•Skeletal muscle dysfunction
FEV1, PEFR
FRC, IC
6 Min walk
Dyspnea score
Exacerbation
ó อาการóExacerbationóDyspnea scoreó PEFRóBMIó 6 minute walk
การประเมินโรค
77
ขณะนี ้อาการเหนื่อยหอบของคุณเปนอยางไรบาง0. ไมมีอาการเหนื่อย เพียงแครูสึกหายใจหอบเฉพาะ ขณะออกกําลังกายอยางหนักเทานั้น
1. หายใจหอบ เม่ือเดินอยางเรงรีบบนพื้นราบ หรือเม่ือเดินขึ้นท่ีสูงชัน2. เดินบนพื้นราบไดชากวาคนอื่นท่ีอยูในวัยเดียวกัน เพราะหายใจหอบ หรือตองหยุดเพื่อหายใจเม่ือเดินปกติบนพื้นราบ
3. ตองหยุดเพื่อหายใจหลังจากเดินไดประมาณ 100 เมตร หรือหลังจากเดินไดสักพักบนพื้นราบ
4. หายใจหอบมากเกินกวาท่ีจะออกจากบาน หรือหอบมากขณะแตงตัว หรือเปลี่ยนเครื่องแตงตัว
Dyspnea score
78
nurse
Doctor
nurse
Pharmacist
•Register patients •Assess severity
Treatment
AppointmentRehabilitation
Inhaler technique COPD education
Dyspnea scores
SpirometryFEV1/ FVC <70%วัดความเร็วสูงสุด
6 Min walk
BMI
80
ó COPD Guideline>>>>>GOLD Guidelineó Changing concept in COPD managementó Irreversible vs incomplete reversible airway obstructionó Inflammatory diseaseó Systemic inflammation
ó The TORCH trialó Pharmacotherapy can slow disease progression.ó SFC improve survival, reduce exacerbation, improve QOL ó SFC is effective in moderate COPD (GOLD stage II)
ó COPD is a preventable and treatable diseaseó Easy COPD is easy
Summaries
81