COPD GUIDELINES Sarah Cowdell

WHY GUIDELINES MATTER Predicted to be the third leading cause of death by 2030 Cause of over 30,000 deaths in the UK yearly Chronically underdiagnosed – ( by up to 1/3 ) The cause of massive spend in healthcare resources (drugs, bed-days, primary care consultations, workdays lost, comorbidities, mortality. Impact on sufferers and their carers

WHATS GOING ON 2010 NICE update ( Gold Guidance) COPD STRATEGY NICE QUALITY INDICATORS Oxygen suppliers reprocurement New HOOF /HOCF New Drugs Community COPD service Community referral pulmonary rehabilitation. ESD Decomissioned OP secondary care work

Wakefield and Kirklees COPD Guidance Diagnosis of COPD Management of Stable Disease Treatment of Acute Exacerbations Taken from the NICE (2004)2010 update

Definition Disease classified by airways obstruction which is not reversible, is usually progressive and does not vary from day today. It will usually occur in smokers or ex smokers over the age of 50. Main symptoms include dyspnoea, cough and sputum production.

Airflow obstruction is defined as a reduction in FEV1/FVC ratio <0.7 No longer necessary to have FEV1 <80% predicted for definition of airflow obstruction* If FEV1 is ≥ 80% a diagnosis of COPD should only be made in the presence of respiratory symptoms and/or reduced ratio. * post bronchodilator

Severity MildReduced FEV1/FVC, Normal FEV1 ModerateFEV % SevereFEV % Very severeFEV1 <30%

FEV1 ≥ 50%FEV1 < 50% SABA or SAMA as required* LABA LAMA** Offer LAMA in preference to regular SAMA four times a day LABA + ICS in a combination inhaler Consider LABA + LAMA if ICS declined or not tolerated LAMA** Offer LAMA in preference to regular SAMA four times a day LABA + ICS in a combination inhaler Consider LABA + LAMA if ICS declined or not tolerated LAMA + LABA + ICS Inhaled therapy Breathless and/or exercise limitation Exacerbations or persistent breathlessness Persistent exacerbations or breathlessness Consider therapy Offer therapy

Thorax February 2011; 66:93-96

Cost implications Fometerol Turbohaler£23.75 Salmeterol MDI£27.80 Salmeterol Accuhaler£29.26 Symbicort Turbohaler£38.00 Seretide Accuhaler£40.92 Seretide MDI£59.58 Tiotropium Handihaler£34.87 Tiotropium Respimat£36.26

Other therapies Carbocisteine – Reduce exacerbations if chronic sputum production- £16.03 Theophylline – May improve breathless, may enhance action of ICS- Approx £5.00 Montelukast – Not recommended for COPD

Summary Bronchodilators improve symptoms No clear benefit of 1 agent over another “Adding on” bronchodilators improves symptoms further Adding on inhaled corticosteroids has a small additional benefit Importance of the inhaler device

Other stuff n.b presence of haemoptysis in a newly diagnosed or otherwise stable pt require urgent fast track referral Chest x-ray FBC/U&E BMI MRC score/Ex tolerance Smoking status Infection frequency Vaccination PLAN Treatment level Disease Info SMOKING CESSATION Review frequency Self-management Pulmonary rehabilitation

CAT COPD assessment test The CAT provides a reliable measure of the impact of COPD on a patients health status Score 5 – (upper limit of normal in healthy non-smokers) Score <10 (low) » Smoking cessation » Annual flu vaccination » Reduce exposure to exacerbation risk factors » Therapy as warranted by further clinical assessment Score (medium) » Review maintenance therapy » Referral for pulmonary rehabilitation » Best approaches to minimizing and managing exacerbations » Review aggravating factors – is the patient still smoking? Score >20 (high) » Additional pharmacological treatments » Referral to pulmonary rehabilitation » Ensuring best approaches to minimising and managing exacerbations Score >30 (very high) » In addition to the guidance for patients with low and medium impact CAT scores consider: » Referral to specialist care

Pulmonary Rehabilitation Offer to all patients who consider themselves functionally disabled by COPD Make available to all appropriate people, including those recently hospitalised from an acute exacerbation [2010] Hold at times that suit patients and in buildings with good access

Pulmonary rehabilitation Paddock Jubilee Centre Twice weekly for 8 weeks Structured exercise programme Education component MRC score of ≥ 3 Transport cannot be provided

12 months before PR 12 months after PR Change Admissions97-22% Length of stay (days) % Bed days %

Managing exacerbations The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators Give self management advice on responding promptly to symptoms of exacerbation. Start appropriate treatment with oral steroids and antibiotics Use of hospital-at-home or assisted-discharge schemes Use of NIV as indicated

EXACERBATIONS A SUSTAINED WORSENING (+ 24 hours) OF SYMPTOMS REQUIRING A CHANGE IN TREATMENT CHANGE IN SPUTUM COLOUR INCREASE IN COUGH CHANGE IN VOLUME OF SPUTUM ( LESS OR MORE) INCREASED BREATHLESSNESS OR TAKING LONGER THAN USUAL TO RECOVER FROM USUAL ACTIVITY Amoxicillin 500mg TDS 7 days Prednisolone 30mg OD 7 days

Reducing mortality

Exacerbations and mortality

Δ (95% CI): 88.9 (44.7,133.2) seconds, p<0.001 Day 1 Day 21 Δ (95% CI): 43.1 (10.9,75.4) seconds, p<0.001 GLOW3: Seebri significantly improved exercise tolerance on Days 1 and 21 against placebo 0 Beeh KM et al. International Journal of COPD, 2012; SBH12-C038 Date of Prep October 2012

What’s New? INDERCATEROL = ONBREZ GLYCOPYRRONIUM BROMIDE = SEEBREE ACLIDINIUM =

Indercaterol - once daily long acting beta2 agonist Dry powder device

GLYCOPYRRONIUM BROMIDE Once daily long acting anti muscarinic MUSCARINIC

Aclidinium Twice daily long acting antimuscarinic Novel inhaler device

Roflumilast Anti-inflammatory, reduces exacerbations Not approved by NICE £37.71 PlaceboRoflumilast Moderate/severe exacerbations (ARR -17%) Use of systemic steroids and/or antibiotics (ARR -16%)

The future? Anti-inflammatories? – Exacerbation reduction – Disease progression? More combinations of current molecules – Once daily triple therapy in 1 inhaler?

conditions/