1. Nottinghamshire COPD and Asthma Guidelines
Dr Esther Gladman
GP Prescribing Lead, Medicines Management Nottingham City CCG
Feb 2012
Introduce self
Documents – who & why
Has anyone read COPD NICE? 350+!
Suck eggs/bacsics
Are you seeing a lot of COPD/asthma/HF
What is difference?

2. Where to find & other resources
Google: Nottinghamshire Area Prescribing Committee
Medicines Traffic Light Classification List
Shared Care Protocols
Clinical Guidelines
Formularies
Policies and Prescribing Position Statements
E-healthscope
(was CKS)

3. e.g. from prodigy : What simple measures can I advise to manage breathlessness for people with end-stage COPD?
Advise the person on the following simple measures to manage breathlessness.
Sitting in front of a fan or open window (or using a hand-held fan).
Positioning
For example, advise the person to sit or stand leaning forward (for example onto a table or the back of a chair) and supporting their weight with their arms and upper body.
Pursed-lip breathing
Advise the person to inhale through the nose and then exhale slowly, for 4–6 seconds, through pursed lips.
Other simple measures, not specific to chronic obstructive pulmonary disease (COPD) but recommended in the section on Simple measures to help dyspnoea in the PRODIGY topic on Palliative cancer care - dyspnoea, may be useful for people with COPD.

4. Nottinghamshire COPD Guideline Key points
Most effective interventions
Be aware other conditions
Effective/cost effective prescribing
Steroid dose, pneumonia & adverse
Be aware side effects and adverse effects of meds
Where can you make a difference?

5. Most Effective Interventions
1. Stopping smoking is the only treatment that slows the progression of COPD
and is the most cost effective treatment in COPD. NNT 5 –to prevent death at age 70
Motivational questioning, cost cigs & inhalers, Allen Carr, anxiety, dopamine,worsening of symptoms, dementia

6. Most Effective Interventions: 2. Pulmonary Rehabilitation
MRC dyspnoea score 3, 4, 5
or recent admission
“more breathless than contemporaries when walking or gets breathless on exertion & needs to rest”
NNT 2 to improve exercise tolerance by a clinically useful amount
NNT 4 to stop readmission over 6/12 if given early after an exacerbation

7. Most Effective Interventions 3. Self Management Plans
NNT 10 to reduce admission in low risk patients
NNT 3 to reduce admission in high risk patients (1 previous admission or LTOT or previous use of Prednisolone)
NNT 5 for patient held “emergency supply pack” (prednisolone +/- antibiotic) to reduce admission

8. Beware diagnosis >40 years old
Smoker or ex-smoker, non-smoking spouse of smoker or dusty occupation
Spirometry FEV1 < 80% predicted and post bronchodilator FEV1/FVC ratio < 70% and typical symptoms
NB FEV1 – an increase of >400ml after bronchodilator suggests asthma not COPD
Consider CXR/FBC, ECG for alternative diagnoses or red flag symptoms such as haemoptysis

9. Be aware: are symptoms in accord with severity of COPD?
FEV1 Rapid decline? e.g. >200ml in 3 years, exacerbations/Excess sputum
Re-assess for co-morbidity, treatment adherence, inhaler technique
Consider bronchiectasis
check sputum for unusual organisms/Acid & Alcohol Fast bacilli
? Ca CXR,FBC,ECG
NB 25 % will have IHD/ cardiac failure

10. Consider stepping down/swopping
Explanation of flow chart
Look at flow chart in conjunction with
Stop smoking
Optimise inhaler technique (e.g. spacers with MDIs) and review regularly
Consider stopping new treatment if patient feels no improvement (4 weeks)
longer may be needed for a reduction in exacerbations
Consider stepping down/swopping
There is no combination MDI licensed for COPD if patient preference:
Fostair 100/6 (2 puffs BD £29.32)
or Seretide spacer (2puffs BD, £35) can be considered, which gives similar ICS dose to Accuhaler 500.
NB Seretide 250 MDI is not recommended
High dose ICS (fluticasone 1000 microgram) increase the risk of pneumonia NNH=47
LABA vs LAMA – there is no significant difference re: reduction in exacerbation or hospitalisation rates.
Use tiotropium Spiriva Handihaler® (18 mcg/day) not Spiriva Respimat® (mist device)
All patients must be advised not to exceed the maximum daily dose

11. Effective/cost effective prescribing
Stop smoking
Optimise inhaler technique (e.g. spacers with MDIs)
Consider stopping new treatment if patient feels no improvement (4 weeks)
longer may be needed for a reduction in exacerbations
Consider stepping down/swopping
Look at flow chart in conjunction with
Stop smoking
Optimise inhaler technique (e.g. spacers with MDIs) and review regularly
Consider stopping new treatment if patient feels no improvement (4 weeks)
longer may be needed for a reduction in exacerbations
Consider stepping down/swopping

12. Effective/cost effective prescribing
LABA vs LAMA – there is no significant difference re: reduction in exacerbation or hospitalisation rates.

13. Effective/cost effective prescribing
There is no combination MDI licensed for COPD
However if patient preference:
Fostair 100/6 (2 puffs BD £29.32)
or Seretide spacer (2puffs BD, £35) can be considered, which gives similar ICS dose to Accuhaler 500.
NB Seretide 250 MDI is not recommended

14. Adverse effects of steroid
High dose ICS (ie fluticasone 1000 mcg = Seretide 250) increases the risk of pneumonia, NNH = 47
ie. Beware those with frequent exacerbations
Other steroid effects - Diab/thrush/cataracts
Osteoporosis prophylaxis for patients having 4 courses of oral steroid within 12 months

15. Be aware side effects and adverse effects of meds
Use tiotropium Spiriva Handihaler® (18 mcg/day) not Spiriva Respimat® (mist device)
All patients must be advised not to exceed the maximum daily dose
All anticholinergics have some cardiovascular effect
Fometerol and beta agonists also have effect

16. NBs
Mucolytic only if troublesome phlegm: carbocisteine 750mg TDS (£24.60) can be trialled for 4 weeks.
Stop if no effect.
Drop to maintenance dose: 750mg BD if effective.
Consider using in winter months only.
Mucolytics do not prevent exacerbations
Consider theophylline 3rd line: Uniphyllin 200mg BD (£2.94) care with elderly & concomitant medications see BNF. Theophylline levels? NNT=33

17. NBs
25% will have co-morbidity e.g. IHD/cardiac failure. Beta blockers can be used in COPD
Dose of emergency supply pack?

18. Actions Flu & pneumococcal vaccination Inhaler use/Medication /step
Stop smoking advice /refer New Leaf
Patient info/empowerment
MRC dyspnoea score 3, 4 or 5/functional disability refer for pulmonary rehabilitation
Self management plan and anticipatory prescription pack
Weight/diet/exercise. Little & often leaflets

19. Oxygen Sat ≤92% - refer to chest clinic /oxygen assessment service
Palliative Care Planning If end-stage COPD/cor pulmonale

20. Nottinghamshire Adult Asthma Treatment Summary
Micro break & shake
Break & shake

21. Nottinghamshire Asthma Guideline Key points
Step up and down
Use LABA and ICS in a combination inhaler
Be aware of inhaler equivalent steroid doses
Step 3a is addition of LABA not increase ICS too
Twitchiness of asthma
Same steroid risks as for COPD
Pros & cons of SMART
Theophylline levels/interactions

22. Step Consider stepping up if: Consider stepping down if :
1. Using SABA 3 times a week or more
2. Symptoms 3 or > times x week
3. An exacerbation in the last 2 years
4. Waking due to symptoms one night a week
Ensure adherence and inhaler technique
Consider stepping down if :
Asthma control has been good for 3 months on current therapy
N.B. Steroid dose reductions should be slow as patients deteriorate at different rates. Reduce by 25-50% & monitor

23. Appropriate spacer/ Other devices? Peak flow meter?

26. Step 3a nb add LABA only

27. Step 3b & c

28. Step 3 alternative

29. SMART Pros: opener & reliever, inc dose steroid when need it Cons: device, symptoms, side effects

30. Step 4 asthma nb this is where use of Seretide 250 MDI is appropriate

32. nb
Oral steroid - sometimes higher dose & shorter course than COPD
Same steroid risks as for COPD
Written Self-Management Plan/lifestyle/house dust mite/patient beliefs/info
Co-morbidity

33. Key points summary
Step up and down
Always give LABA and ICS in combination inhaler (unlike COPD)
Step 3a is addition of LABA not increase ICS too
Be aware potency of ICS Inhaler and equivalent steroid doses