1. New inhalers for COPD and asthma 2015
Dr Will McConnell
Dorset County Hospital

2. Mrs Jenkins of Sturminster Newton
Mrs Win Langley of Croydon

3. FEV1 1.1 litres
FVC 2.2 litres

4. Fletcher- Peto curve 1977

5. Lange et al (1998) 15 year follow up of 1000 asthmatics

6. Lange et al New Engl J Med July 2015
Long term follow up of normal adults with spirometry
Half of those who developed COPD had normal FEV1 to start with and had an accelerated decline in lung function
The other half had a low FEV1 to start with and a normal rate of decline in lung function

7. Revised Fletcher- Peto-McConnell curve 2015
Low starting FEV1
FEV1 50% predicted
Asthma
COPD

8. Asthma/COPD Overlap Syndrome
Asthma or COPD?
ACOS
Asthma/COPD Overlap Syndrome

9. National Review of Asthma Deaths (NRAD) 2014 www.rcplondon.ac.uk/NRAD
Why asthma still kills
National Review of Asthma Deaths (NRAD) 2014
Rachael Andrews NRAD programme coordinator, Royal College of Physicians (RCP)
Rhona Buckingham Operations director, Clinical Effectiveness and Evaluation Unit (CEEU), Royal College of Physicians (RCP)
Hannah Evans Medical statistician, Royal College of Physicians (RCP)
Caia Francis Senior lecturer in adult nursing, University of the West of England, and former chair, respiratory forum,
Royal College of Nursing (RCN)
Rosie Houston NRAD programme manager, Royal College of Physicians (RCP) (until February 2013)
Derek Lowe Medical statistician, Royal College of Physicians (RCP)
Dr Shuaib Nasser Consultant allergist and respiratory physician; British Society for Allergy and Clinical Immunology (BSACI);
Eastern Region Confidential Enquiry of Asthma Deaths
Dr James Y Paton Reader in paediatric respiratory medicine, Royal College of Paediatrics and Child Health (RCPCH)
Navin Puri Programme manager for respiratory medicine

10. Small airway in fatal asthma
mucus plugging
epithelial shedding
thickening internal to smooth muscle
increased smooth muscle
thickening external to smooth muscle

11. LABAs in asthma - risks

12. Salmeterol taken alone is associated with increased asthma deaths - better with inhaled steroids...

16. Issues to consider when choosing an inhaler for COPD
Evidence of Efficacy - consider what you are trying to achieve with the treatment
Breathlessness –
LABAs and LAMAs are effective –
generally LAMAs produce greater bronchodilatation and are best tried first –
adding LABA/LAMA combinations produce greater bronchodilatation
Exacerbation reduction –
inhaled steroids, used in combination with LABAs, have the strongest evidence of efficacy.
LABAs and LAMAs have varying evidence for exacerbation reduction, with the strongest evidence in favour of glycopyrronium, tiotropium, and indacaterol, with somewhat lesser benefits with salmeterol and formoterol.

17. Issues to consider when choosing an inhaler for COPD
Device - choose a device to suit the patient *
Is there inspiratory flow insufficient for a powder inhaler, so they need an MDI (eg Fostair, Respimat)?
Can they manage a traditional pMDI (eg Fostair)? With spacer?
Could they manage to insert a capsule (eg Breezhaler, Handihaler)?
Would they favour a device with less coordination and fewer steps (eg Ellipta, DuoResp Spiromax, Genuair)?
Once daily or Twice daily –
some patients favour the ease of once daily, others prefer to have an extra dose per day
Cost –
there is potential for significant cost savings with the newer devices

18. Issues to consider when choosing an inhaler for COPD
Side effects - eg
Some patients develop palpitations with LABAs or dry mouth with LAMAs.
LAMAs have generally not been tested in patients with a history of recent, unstable or life threatening cardiac problems (arrhythmias, IHD or heart failure), so should be used with some caution
High dose inhaled corticosteroids increase fracture risk and risk of pneumonia, with some studies suggesting that budesonide-containing inhalers have a lesser increased risk of pneumonia than other inhaled corticosteroids.
Stopping Treatments – try stopping treatments that appear to give little or no benefit.
Review patients 2-3 months after starting a new treatment and stop it if there is no symptomatic benefit
Review inhaled corticosteroids if there have never been COPD exacerbations but difficult to assess benefit to inhaled steroids over short periods
Consider stopping mucolytics if there are no expectoration problems

19. The old long acting bronchodilators
LABA
Salmeterol
Formoterol
Disadvantages
variable data on reducing exacerbations
Twice daily
Only lead to about 70ml increase in FEV1
LAMA
Tiotropium
Handihaler
Respimat
Greater degree of bronchodilatation
Fairly good exacerbation reduction

20. Newer long acting bronchodilators for COPD
LABA
Indacaterol (150 mcg od)
Olodaterol (5 mcg od)
LAMA
Glycopyrronium (50 mcg od)
Umeclidinium (55 mcg od)
Aclidinium (400 mcg bd)
Combination inhalers
Ultibro ▼ – indacaterol/glycopyrronium
Anoro ▼ - umeclidinium/vilanterol
Spiolto – tiotropium/olodaterol
Duaklir ▼ - aclidinium/formoterol

21. What about inhaled steroids in COPD?
Older ones
Seretide
Symbicort
Newer Ones
Relvar
DuoResp Spiromax
Fostair

23. Relvar first once daily ICS/LABA
For COPD and asthma
Fluticasone furoate and vilanterol
COPD dose is 92 mcg od
Can go up to 184 mcg od for asthma
Reduces COPD exacerbations by 27% compared to vilanterol alone

26. So what to choose that are currently on formulary for asthma?
Low-medium dose inhaled steroids
Qvar or Clenil
High dose inhaled steroid
Clenil
Low or medium dose LABA/ICS combo
Fostair (MDI or Nexthaler DPI)
Duoresp spiromax DPI
Relvar DPI (medium dose only)
High dose LABA/ICS combo
Relvar DPI

27. Integrated Respiratory Service
DAIRS
Dorset Adult
Integrated Respiratory Service

28. Summary There are new useful, cheaper drugs for COPD indacaterol
glycopyrronium, aclidinium, umeclidinium
LABA/LAMA combos
Relvar, Fostair
Try to avoid inhaled steroids in COPD unless there are exacerbations BUT in asthma use inhaled steroids early
Not all inhaled steroids are the same – and there are cost savings to be had