1. COPD – Primary Care Update
Andrew White & Charles Buckley

2. Definition of COPD
‘Chronic obstructive pulmonary disease (COPD), a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced inflammatory response in the airways and lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients’ Global initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines February 2013

3. Basics Mainly smoking related 2-4% of the adult population
4th leading cause of death (set to rise)
10% of all emergency admissions
A major burden on NHS resources

4. Basics of evidence based management
Stop smoking
Flu and pneumonia immunisation
Pulmonary rehabilitation
Oxygen therapy for those with significant hypoxia
Prompt treatment of exacerbations with steroids and antibiotics
Inhalers????

5. COPD Value pyramid
London Respiratory Team

6. Inhaled therapy Short acting bronchodilators
Long acting bronchodilators
What about inhaled corticosteroids?

7. Inhaled steroids in COPD
No benefit in mild/moderate COPD – no effect of lung function or exacerbation rate (Vestbo, Lancet 1999)
Lung Health Study showed “fewer visits to primary care physician” in triamcinalone treated group vs placebo (N Eng J Med 2000)
Studies on more severe disease with FEV1 <50% predicted reported fewer exacerbations in those treated with steroids (Burge PS, BMJ 2000; Alsaeedi A, Am J Med 2002) Approx reduction of 30%
Methods overestimated effect

8. Benefits if ICS in COPD?
Some reduction in mild exacerbation with ICS/LABA vs LABA alone
No reduction in hospital admissions
NNT with Seretide 500 vs Salmeterol 50 alone = 14 to prevent 1 exacerbation (controversial) (Suissa, Thorax 2013)

9. Pneumonia and other adverse effects of ICS
70% increase in pneumonia requiring hospitalisation (Ernst P, 2007; Am J Resp Crit Care Med)
44 patients must be treated for 3 years to prevent 1 exacerbation vs 16 over 3 years to result in 1 pneumonia (Suissa, Thorax 2012)
34% relative risk of developing new onset diabetes and 34% risk of progressing to insulin dependence among those on oral hypoglycaemics.
Risk of adrenal insufficiency greater in COPD patients.

10. Can we safely stop inhaled steroids in COPD
Withdrawal of steroids results in increased exacerbations (Jarad NA Respir Med 1999; Choudhury AB Respir Res 2007)
WISDOM trial showed no increased exacerbation rate in patients if the ICS was reduced in a stepwise fashion
500 FDP bd then 250 bd then 100 bd then stop.
(Magnussen H, N Eng J Med 2014)

11. Azithromycin prophylaxis
COLUMBUS trail: Azithromycin resulted in approximate 40% reduction in exacerbations compared to placebo (Uzun, Lancet Respiratory Medicine 2014)
Albert et al found 17% reduction in exacerbations (N Engl J Med2011)
Donath et al for 37% reduction in meta analysis (Respir Med 2013)
BUT QT prolongation and some effects on hearing
Strep pneumoniae macrolide resistance in Gloucestershire is double the national average.

12. Phenotypes
Can better characterisation of COPD determine response to treatment?

13. FEV1 = 44% predicted
FEV1/FVC = 0.51

14. FEV1 = 39% predicted
FEV1/FVC = 0.42

15. COPD and FEV1 COPD defined by FEV1 and FEV1/FVC
FEV1 correlates poorly with
Breathlessness
Exacerbations
Health status
Response to treatment
Reversibility tests
Do not reliably predict treatment response

16. COPD stage – traditional model

18. Patient* is now in one of four categories:
GOLD guidelines 2013: Stable COPD: Combined assessment of symptoms + spirometry + exacerbation risk1
Figure 2.3: Association between symptoms, spirometric classification and future risk of exacerbation
Patient* is now in one of four categories:
A: Less symptoms, low risk
B: More symptoms, low risk
C: Less symptoms, high risk
D: More symptoms, high risk
* When identifying the Patient Group to which a patient belongs, if their level of risk is different between their GOLD grade and their exacerbation history assessment, choose the method indicating the highest risk
1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease (updated Feb 2013).

19. ICS+LABA and PDE4-inh. or
Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy
Patient
Recommended
First choice
Alternative choice
Other Possible
Treatments A
SAMA prn or
SABA prn
LAMA
LABA
SABA and SAMA
Theophylline B
LAMA and LABA
SABA and/or SAMA C
ICS + LABA
LAMA and LABA or
LAMA and PDE4-inh. or
LABA and PDE4-inh. D
and/or
ICS + LABA and LAMA or
ICS+LABA and PDE4-inh. or
LAMA and PDE4-inh.
Carbocysteine

20. COPD Phenotypes Chronic bronchitis and emphysema
Pink puffer and blue bloater
Newer concepts
Asthma-COPD overlap syndrome (ACOS)
Exacerbator phenotype
2 or more exacerbations/year
Emphysema/hyperinflation phenotype

21. Asthma COPD Overlap Syndrome
Patients fulfil spirometric definition of COPD
Have a history of asthma diagnosed before age 40yrs
Have less emphysema
Have greater bronchial wall thickening
Tend to exacerbate more
Have greater eosinophilic airway inflammation
Benefit from ICS

22. Lung Volume Reduction
Treatment for hyperinflation related breathlessness in emphysema

23. Lung volumes in COPD/emphysema
Normal Lung
COPD/Emphysema Lung

25. Lung volume reduction

26. Endobronchial valves

27. Endobronchial valves

28. Lung volume reduction coil

33. Conclusion
Influenza and pneumococcal vaccination and smoking cessation are the most cost effective interventions
Pulmonary rehabilitation and long acting bronchodilators are both cost effective and complementary
Oxygen for hypoxic patients
Inhaled steroids only for those with coexistant “asthma”/ACOS and for those with frequent exacerbations not already controlled with LABA/LAMA
Consider withdrawal of ICS in patients who should never have been put on it!
Consider referral for younger, more severe and when there is diagnostic doubt or consideration for LVR.