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Copd 2017

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Copd 2017

  1. 1. eladawy
  2. 2. 4
  3. 3. 5 Pharmacological treatment of COPD (Lots of inhalers, lots of names…)
  4. 4. 6
  5. 5. 7 More useful to classify in terms of classes
  6. 6. Children’s Healthcare of Atlanta
  7. 7. 9
  8. 8. 10
  9. 9. 11
  10. 10. 12
  11. 11. 13 lobal Initiative for Chroniclobal Initiative for Chronic bstructivebstructive ungung iseaseisease G O L D
  12. 12. 14
  13. 13. 15 GOLD2001GOLD2001 GOLD2011GOLD2011 GOLD2017GOLD2017
  14. 14. 16
  15. 15. 17 Road Map
  16. 16. 18 Clinical diagnosis Spirometry Gold Severity stage Drugs a/t stages COPD: Management
  17. 17. 19
  18. 18. 20
  19. 19. 21
  20. 20. 22
  21. 21. 23 Manage Stable COPD
  22. 22. 24
  23. 23. Children’s Healthcare of Atlanta 25 Role of Bronchodilators in COPD
  24. 24. 26
  25. 25. 27
  26. 26. 28
  27. 27. 29 Expiratory flow-limitation and lung hyperinflation that are only partially reversible to bronchodilator therapy are pathophysiological hallmarks of COPD
  28. 28. Children’s Healthcare of Atlanta V BD  Air flowDeflation  Improvement in flow – FEV1  Improvement in volumes – FVC and IC Bronchodilator therapy deflates the lung BD = bronchodilator; V = ventilation; FEV1= forced expiratory volume in 1 second; FVC= forced vital capacity; IC = inspiratory capacity
  29. 29. Children’s Healthcare of Atlanta 31
  30. 30. 33
  31. 31. Approaches of COPD treatment according to GOLD guidelines Timeline Unidimensional approach Multidimensional approach GOLD 2001 GOLD 2011 1) Risk: FEV1 Rate of exacerbations 2) Symptoms: CAT score, mMRC scale
  32. 32. 36 • Looks at 3 things (combined assessment): 1) FEV1 2)Symptoms 3)History of exacerbations Revised GOLD classification
  33. 33. 37
  34. 34. 38 0-1 = less breathlessness >2 = more breathlessness
  35. 35. 39 Cough Sputum Chest tightness Walking up hill ADLs Leaving the house Sleep Energy levels
  36. 36. 41
  37. 37. 42 Less symptoms High risk Less symptoms High risk Less symptoms Low risk Less symptoms Low risk More symptoms high risk More symptoms high risk More symptoms low risk More symptoms low risk (GOLDClassificationofAirflowLimitation) Risk CAT < 10 Breathlessness mMRC 0–1 mMRC ≥ 2 Symptoms CAT≥10 ≥2 or 1 (not leading to hospital admission) 0 ≥1 leading to hospital admission GOLD 2011 Combined assessment of COPD
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  42. 42. 47 GOLD2017GOLD2017
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  44. 44. 49 Bronchodilators Continue , stop or try alternative class of bronchodilators Evaluate effect Group A Group B A long – acting bronchodilators ( LABA or LAMA ) LAMA + LABA Persistent Symptoms Group C LAMA LAMA + LABA LABA + ICS Further exacerbation(s) Group D LAMA LAMA + LABA LABA + ICS LAMA + LABA + ICS Consider Roflumilast if FEV1 50% pred.˂ And patient has chronic bronchitis Consider macrolides in former smokers Further exacerbation(s) Further exacerbation(s) Persistent Symptoms / further exacerbation(s)
  45. 45. 50
  46. 46. 51 • "This is a major revision of the GOLD document since 2011 and is a step forward for individualised COPD management. • The updated pharmacotherapy recommendations are now based solely on two factors, symptoms and exacerbation history," GOLD2017GOLD2017
  47. 47. 52 Revised combined COPD assessment • A refinement of the ABCD assessment tools is proposed that separates spirometric grades from the “ ABCD “ groups • ABCD groups will be derived exclusively from patient symptoms & exacerbations history • Spirometery in conjugation with patient symptoms & exacerbation history remains vital for : 1) Diagnosis 2) Prognostication 3) Therapeutic approaches
  48. 48. 53
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  50. 50. 55
  51. 51. 56  All Group A patients should be offered bronchodilators treatment based on it’s effect on breathlessness ( this can be either short- or long-acting bronchodilator ) .  This should be continued if symptomatic benefits is documented.  if necessary, an alternative class of bronchodilator (alternative mono bronchodilator )can be used if benefit is not achieved with the first.
  52. 52. 57
  53. 53. 58 Group B A long – acting bronchodilators ( LABA or LAMA ) LAMA + LABA Persistent Symptoms
  54. 54. 59  For Group B patients, therapy should begin with a long- acting bronchodilator LABA or LAMA , (no evidence to recommend one over another), and should be escalated to two bronchodilators if breathlessness continues with monotherapy.  If breathlessness is severe, starting the patient on dual long-acting bronchodilators can be considered, however if the second therapy does not improve symptoms, the guidelines suggest stepping down to one bronchodilator.
  55. 55. 60 Long-Acting Bronchodilators • LAMAs • Block acetylcholine- mediated bronchoconstriction (via M3 receptors) – Tiotropium – Aclidinium – Glycopyrronium (glycopyrrolate) – Umeclidinium • LABAs • Direct relaxant activity on airway smooth muscle (via β2 adrenoceptors) – Formoterol – Salmeterol – Indacaterol – Oldaterol – Vilanterol
  56. 56. 61 LAMA DPI HandiHaler/ SMI Respimat Spiriva® (tiotropium) DPI Breezhaler Seebri® (glycopyrronium) DPI Genuair Eklira® (aclidinium) DPI Ellipta Incruse® (umeclidinium) LAMA inhalers for COPD
  57. 57. 62 LAMA DPI HandiHaler/ SMI Respimat Spiriva® (tiotropium) DPI Breezhaler Seebri® (glycopyrronium) DPI Genuair Eklira® (aclidinium) DPI Ellipta Incruse® (umeclidinium) LAMA inhalers for COPD
  58. 58. 63
  59. 59. 64
  60. 60. 65
  61. 61. 66 LABA DPI Diskus Serevent® (salmeterol) DPI Aerolizer Foradil® (formoterol) DPI Breezhaler Onbrez® (indacaterol) SMI Respimat Striverdi® (Olodaterol)
  62. 62. 67
  63. 63. 68
  64. 64. 69 Fixed-dose combination LABA/LAMA DPI Ellipta Anoro® (vilanterol/umeclidinium) DPI Breezhaler Ultibro® (indacaterol/glycopyrronium) SMI Respimat Inspiolto® (olodaterol/tiotropium) DPI Genuair Duaklir® (formoterol/aclidinium) Combination LABA/LAMA inhalers for COPD
  65. 65. 70
  66. 66. 71
  67. 67. 72 Group C LAMA LAMA + LABA LABA + ICS Further exacerbation(s)
  68. 68. 73  For Group C patients, it is recommended that treatment be started with a single long-acting bronchodilator, preferably a LAMA (LAMA was superior to the LABA regarding exacerbation prevention).  A second long-acting bronchodilator or the combination of LABA/ICS may be used for persistent exacerbations;  The guidelines recommend LABA/LAMA as the addition of ICS has been shown to increase pneumonia risk in some patients.
  69. 69. 74 Inhaled Steroids in COPD  Exacerbation reduction when added to LABD in placebo- controlled trials  Improvement in FEV1 in combination with beta- agonists  Clinical trial evidence o No reduction in COPD progression o No mortality reduction  Side effect profile o Risk of pneumonia o Risk of osteoporosis, adrenal suppression o Hoarse voice o Oral Thrush ConsPros Burge PS, et al. BMJ. 2000;320(7245):1297-1303. Calverley PM, et al. NEJM. 2007;356:775-789. Festic E, et al. AJRCCM. 2015;191:141-148. Kaplan AG. Int J COPD. 2015;10:2535-2548. Suissa S, et al. Eur Resp J. 2015;46:1232-1235.
  70. 70. 75 Risk of patients with COPD developing serious pneumonia is particularly elevated and dose-dependent with fluticasone propionate use, and comparatively much lower with budesonide. Based on the latest EMA review on ICS for COPD overall the benefits of inhaled corticosteroid medicines in treating COPD continue to outweigh their risks
  71. 71. 76 ICS/LABA DPI Diskus Advair® (Fluticasone/salmeterol) DPI Turbuhaler Symbicort® (Budesonide/formoterol) DPI Ellipta Relvar® (Fluticasone/vilanterol)
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  75. 75. 80 Group D LAMA LAMA + LABA LABA + ICS LAMA + LABA + ICS Consider Roflumilast if FEV1 50% pred.˂ And patient has chronic bronchitis Consider macrolides in former smokers Further exacerbation(s) Further exacerbation(s) Persistent Symptoms / further exacerbation(s)
  76. 76. 81  For Group D patients, a LABA/LAMA combination is preferred as initial therapy over LABA/ICS as these patients may be at higher risk of developing pneumonia with ICS use.  For patients with high blood eosinophil counts or those with asthma-COPD overlap, LABA/ICS could be considered first-line therapy.
  77. 77. 82  The GOLD Report also reinforces the role of ICS/LABA for patients that have asthma features and/or high blood eosinophil count, and patients who show more frequent exacerbations.  For the first time the GOLD Report recognises eosinophils as a potential decision-driver for COPD treatment and as a biomarker for risk of exacerbations and identifying ICS responders
  78. 78. 83 In patients who develop further exacerbations on LABA/LAMA therapy we suggest two alternative pathways: 1.Escalation to LABA/LAMA/ICS (Triple therapy). 2.Switch to LABA/ ICS If LABA/ICS therapy does not positively impact exacerbations/symptoms a LAMA can be added.
  79. 79. 84
  80. 80. 85 • For patients who still have exacerbations with LABA/LAMA/ICS, the following three options can be considered: • 1) adding roflumilast (for patients with FEV1<50% predicted and chronic bronchitis) • 2) adding a macrolide (azithromycin preferred, however, antibiotic resistance should be factored in decision- making) • 3) discontinuing ICS.
  81. 81. 86
  82. 82. 87
  83. 83. 88
  84. 84. Children’s Healthcare of Atlanta 89
  85. 85. 90 Is ICS Withdrawal or Step Down Therapy Possible in COPD?
  86. 86. 91 The Role of Inhaled Steroids in COPD Pharmacotherapy  There is no advantage in adding ICS to bronchodilator therapy in patients at low risk of exacerbations .  Early observational studies suggested that simply stopping therapy increased the risk of exacerbations. However more recent data suggest that this may not be true if the patient is receiving long-acting inhaled bronchodilators .
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  90. 90. 95 6-7 0 S C R E E N I N G Treatment 52Week -6 ICS (remained on triple therapy from run-in) Stepwise ICS withdrawal (remained on dual bronchodilator) Run-in Triple therapy 12 R A N D O M I S A T I O N ICS stepwise withdrawal Stable treatment Reduced to 250 µg BID Reduced to 100 µg BID Reduced to 0 µg (placebo) Fluticasone propionate 12-week withdrawal schedule 500 µg BID 18 • Tiotropium 18 µg QD • Salmeterol 50 µg BID • Fluticasone propionate 500 µg BID Triple therapy regimen WISDOM: Study design
  91. 91. 96 WISDOM (Withdrawal of Inhaled Steroids During Optimised bronchodilator Management) study
  92. 92. 97 Stepping Down ICS: A Proposed Algorithm Kaplan AG. Int J COPD. 2015;10:2535-2548.
  93. 93. 98
  94. 94. Children’s Healthcare of Atlanta 99
  95. 95. 100  Triple therapy may be over used in COPD patients today so , Constant evaluation of COPD patients and changes in patient status over time is essential to good patient care  Step down therapy, by stopping ICS use in patients on triple therapy , may be considered under the right set of conditions in selected patients  Patients undergoing treatment step down require close monitoring to insure no adverse effects over time, especially COPD exacerbations, are associated with the change in therapy.
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  97. 97. 102 Bronchodilators Continue , stop or try alternative class of bronchodilators Evaluate effect Group A Group B A long – acting bronchodilators ( LABA or LAMA ) LAMA + LABA Persistent Symptoms Group C LAMA LAMA + LABA LABA + ICS Further exacerbation(s) Group D LAMA LAMA + LABA LABA + ICS LAMA + LABA + ICS Consider Roflumilast if FEV1 50% pred.˂ And patient has chronic bronchitis Consider macrolides in former smokers Further exacerbation(s) Further exacerbation(s) Persistent Symptoms / further exacerbation(s)
  98. 98. 103
  99. 99. 104  Treatment recommendations are tailored to patient needs based only on symptoms and exacerbation history.  For patients with only occasional symptoms, a short acting bronchodilator, either a short-acting beta-agonist (SABA) or a short-acting muscarinic antagonist (SAMA) is recommended.
  100. 100. 105  For patients with persistent symptoms, either a (LABA) or a (LAMA) is recommended.  For patients with persistent symptoms on single bronchodilator therapy, advancement to dual therapy with a LAMA plus a LABA, or combination ICS/LABA is recommended, with a preference given to dual-bronchodilator therapy.
  101. 101. 106  ICS are not recommended as monotherapy in COPD .  ICS-containing pharmaceutical regimens no longer recommended as first-choice treatments for COPD of any severity .  Combination agents containing ICS + LABA are considered appropriate step-up therapy for patients experiencing COPD exacerbations while taking long-acting bronchodilators.
  102. 102. 107  The new GOLD Strategy provides clear guidance on when and in which patients ICS can be added or withdrawn.  Only those who have ≥2 exacerbations/year or ≥1 leading to hospital admission may be considered for an ICS containing therapy after LAMA/LABA.  In addition, the new GOLD Strategy suggests that ICS therapy may be withdrawn safely (de-escalation path ) in people with COPD who are in GOLD group D and stable, by using a LAMA/LABA regimen.
  103. 103. 108  The updated 2017 GOLD Strategy now positions a combination of a LAMA (long-acting muscarinic receptor antagonists ) and a LABA (long-acting beta2-agonist), as a mainstay treatment for people with COPD in GOLD groups B-D.  This represents a significant change versus previous GOLD guidelines.
  104. 104. 109  The GOLD Report acknowledges the potential benefits of escalation to triple therapy for those patients who are still exacerbating despite a LAMA/LABA or still symptomatic on ICS/LABA .  The GOLD Report now mentions roflumilast ( PDE-4 inhibitor ) as an additional treatment option on top of triple therapy in patients with FEV1 <50% predicted and chronic bronchitis who still have exacerbations .
  105. 105. 110  Inhaled bronchodilators preferred over oral bronchodilators (A)  Theophylline not recommended; only to be used if other long- term treatments are not available or unaffordable (B)
  106. 106. 111
  107. 107. 112  LAMA/LABA therapy now an essential cornerstone for COPD treatment across the spectrum of people with COPD in GOLD groups B-D  Clearer guidance for physicians on which subset of patients may benefit from the addition of ICS The Winner of GOLD 2017
  108. 108. 113  GOLD 2017 represents a big win for makers of the next- generation LAMA+LABA combination inhaler treatments.  Once-daily combination inhalers for COPD will likely result in better adherence, which could result in improved health outcomes compared to those regimens requiring multiple devices .
  109. 109. 114  The newest COPD combination inhalers aren't on all formularies and will be out of financial reach for many patients .  The 2017 GOLD guidelines emphasizing:  The choice of inhaler device has to be individually tailored and will depend on access, cost, prescriber, and most importantly the patient's ability and preference .  In other words, the best inhaler for COPD is the one a patient can afford, understands, agrees with and will use regularly.
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  114. 114. 119 I cannot afford my COPD medications… what can I do? Are there any affordable treatment alternatives?
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  121. 121. The Role of Health Professionals In Tobacco Control
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