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PREVENTING COPD EXACERBATIONS Christopher Worsnop Department of Respiratory and Sleep Medicine Austin Hospital Melbourne, Australia.

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Presentation on theme: "PREVENTING COPD EXACERBATIONS Christopher Worsnop Department of Respiratory and Sleep Medicine Austin Hospital Melbourne, Australia."— Presentation transcript:

1 PREVENTING COPD EXACERBATIONS Christopher Worsnop Department of Respiratory and Sleep Medicine Austin Hospital Melbourne, Australia

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4 COPD DEFINITION Progressive airflow obstruction that is not fully reversible. Most COPD is due to cigarette smoking Saetta et al AJRCCM 2001; 163: 1304 Hogg et al NEJM 2004; 350: 2645 Lancet 2009; 374:

5 7,716 people with COPD hospitalised in 2011/12. An average of 1.5 times per person. 30 day readmission rate of 17.9%. Average length stay of 4.2 days. Average cost per hospitalised patient was about $7,700. COPD contributed to $54 million in hospitalisation costs (20.3% of total respiratory hospitalisation costs). BURDEN OF COPD IN NEW ZEALAND National Health Committee report, New Zealand, December 2013.

6 Global Strategy for Diagnosis, Management and Prevention of COPD Assess Risk of Exacerbations To assess risk of exacerbations use history of exacerbations and spirometry:  Two or more exacerbations within the last year or an FEV 1 < 50 % of predicted value are indicators of high risk.  One or more hospitalizations for COPD exacerbation should be considered high risk. © 2014 Global Initiative for Chronic Obstructive Lung Disease

7 A B C D SYMPTOMS mMRC 0-1 mMRC 2-4 CAT 10 RISK GOLD STAGE based on FEV RISK Exacerbations per year >

8 ACUTE COPD EXACERBATION The cause is often unknown Respiratory infections –bacterial, viral, - URTI, bronchitis, pneumonia Heart failure, arrhythmia Systemic infection, fever Anaemia Anxiety Anything that increases metabolic rate ERJ 2007; 29: 1224

9 COPD exacerbations 30 % bacterial, 23 % viral, 25 % both, 22 % other ERJ 2007; 29: Various studies show a wide range of organisms, but few atypical bacteria (Legionella, Chlamydia, Mycoplasma). Antibiotics recommended if type I Anthonisen, or type II with purulent sputum, or NIV.

10 CLASSIFICATION OF COPD EXACERBATION A = AIRWAY VIRAL INFECTION B = BACTERIAL INFECTION (including pneumonia) C = CO-INFECTION D = DEPRESSION/ANXIETY E = EMBOLISM (pulmonary) F = FAILURE (cardiac or lung integrity) G = GENERAL ENVIRONMENT X = NO SPECIFIC CAUSE IDENTIFIED Martin MacDonald et al Respirology 2011; 16: 264

11 Features of a COPD exacerbation Anthonisen criteria: - increased dyspnoea - increased sputum production - sputum becoming discoloured Antibiotics to cover Strep and Gram negatives have been shown to be useful if all three criteria are present. CXR to look for pneumonia, and cover atypical bacteria if there is pneumonia.

12 COPD exacerbations Past exacerbations predict future ones. ECLIPSE NEJM 2010; 363: 1128 Patients under report exacerbations AJRCCM 2008; 177: 396. Chest 2008; 133: 34. ERJ 2010; 35: 1022.

13 Death after a COPD exacerbation 40 % mortality in the 12 months after a hospital admission for a COPD exacerbation. AJRCCM 1996; 154: 959 Predictors of mortality: older age, lung cancer, BMI < 20, CV disease, past hospital admissions, needing supplemental O 2 on discharge, use of accessory muscles. ERJ 2013: 42; 946.

14 MANAGEMENT OF COPD STOP SMOKING MEDICATIONS VACCINATIONS REGULER EXERCISE (pulmonary rehabilitation)

15 STOP SMOKING

16 Smoking cessation in Lung Health Study 72 ml fall over 2 years in those who ceased smoking 300 ml over 2 years in those who kept smoking. JAMA 1994; 272: 1497

17 Current medical management of COPD in New Zealand LONG ACTING BETA AGONIST (LABA) –Salmeterol (Serevent) is indicated for long- lasting (12 hour) bronchodilation in adults with reversible airways obstruction due to COPD. – Should not be used in asthma without ICS.

18 LONG ACTING MUSCARINIC ANTAGONIST (LAMA) –Tiotropium (Spiriva) is indicated for the long term once daily maintenance treatment of bronchospasm and dyspnoea associated with COPD, including chronic bronchitis and emphysema. –Special Authority Criteria

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20 Ann Intern Med 2005; 143: TIME TO FIRST EXACERBATION p = TIME TO FIRST HOSPITALISATION p = 0.055

21 Spiriva Placebo p Exacerbation 27.9 % 32.3 % Hospitalization 7.0 % 9.5 % No. of exacerbations per patient per year Exacerbation days Antibiotic days Oral steroid days No. of hospitalizations per patient per year Hospitalization days Ann Intern Med 2005; 143:

22 Eur Respir J 2002; 19: 209. Spiriva Atrovent Spiriva Atrovent p < p < 0.048

23 ICS/LABA Fluticasone / salmeterol (Seretide) is indicated for the symptomatic treatment of patients with moderate to severe COPD (pre- bronchodilator FEV1<60% predicted normal), who have significant symptoms despite bronchodilator therapy.

24 Effects of ICS/LABA combination therapy on inflammatory markers Percentage change from baseline for lung biopsy endpoints: median treatment differences Study population: 140 current and past smokers with moderate to severe COPD

25 Reducing exacerbations with ICS/LABA in severe COPD Kardos et al 2007

26 0.0213% SFC vs FP < % SFC vs sal < % SFC vs placebo p-valueTreatment effect Seretide reduces the rate of exacerbations requiring systemic corticosteroids over 3 years (TORCH) Exacerbation rate placeboSalFP SFC 43% (p<0.001) Calverley PMA et al New Eng J Med 2007; 356:

27 TORCH: different stages of COPD Adapted from Jenkins C, et al. Respiratory Research 2009; 10: 59.

28 Budesonide / eformoterol (Symbicort) is indicated in the regular treatment of adult patients with moderate to severe COPD [FEV1 ≤50% of predicted normal], with frequent symptoms despite beta2-agonist use and a history of exacerbations. SYMBICORT should not be used for the initiation of bronchodilator therapy in COPD

29 Adapted from Szafranski W, et al. Eur Respir J 2003; 21: NS = Not Significant * BUD/FORM vs. each components or placebo * * BUD/FORM vs Placebo BUD/FORM vs BUD BUD/FORM vs FORM BUD vs Placebo FORM vs Placebo NS *

30 Symbicort plus Spiriva versus placebo plus Spiriva Adapted from Welte T, et al. AJRCCM 2009; 180: 741. Number of severe exacerbations decreased by 62%

31 Pneumonia and ICS in COPD Double the pneumonia risk with fluticasone (9 % vs 5% over 2 years), but no increase in mortality. No difference in de novo pneumonia. The difference is only seen in those with worsening COPD prior to the pneumonia. Calverley et al INSPIRE study CHEST 2011; 139:505. Not seen with Symbicort Turbuhaler, but seen with the Rapihaler. Sharafkhaneh A, et al. Respir Med 2012;106:257–68.

32 Newly COPD drugs in New Zealand (but not yet reimbursed) BREO ELLIPTA (ICS/LABA) – Fluticasone fuorate/Vilanterol Symptomatic treatment of patients with COPD with FEV1 < 70 % and past exacerbations.

33 ANORO ELLIPTA (LABA/LAMA) Umeclidinium/Vilanterol Once daily bronchodilator to relieve symptoms in COPD patients.

34 PULMONARY REHABILITATION

35 There is good evidence that it improves symptoms in COPD reduces hospitalizations and length of stay. Patients need to be well motivated. Two main components - improving fitness, and education. A course is run over weeks with twice weekly visits. The exercise needs to be maintained at home. Cochrane database 2006; Lancet 1996; 348: 1115.

36 VACCINES Influenza vaccine - reduces mortality, hospital admissions and exacerbations. - it does not prevent other URTI viruses. - local side effects only. - it is given yearly. NEJM 1994; 331: 778

37 Pneumococcal vaccine - Little evidence about its use in COPD, but it seems like a good idea. - older than 65 NEJM 2003; 348: less than 65 with major comorbidity - less than 65 and FEV1 < 40 % it is given twice 5 years apart in COPD.

38 MANAGEMENT OF COPD STOP SMOKING MEDICATIONS VACCINATIONS REGULER EXERCISE (pulmonary rehabilitation)

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