Update on COPD and Asthma. October 17 th, 2015 Rachel M Taliercio, DO Staff, Respiratory Institute, Cleveland Clinic

Transcription

1 Update on COPD and Asthma October 17 th, 2015 Rachel M Taliercio, DO Staff, Respiratory Institute, Cleveland Clinic

2 What we ll be talking about Update on COPD Diagnosis, management of stable COPD, COPD exacerbations Update on Asthma Diagnosis, management, phenotypes, comorbidities COPD/Asthma overlap syndrome Grab bag Vaccinations, smoking cessation, electronic cigarettes AOA 2015 l October 20, 2015 l 2

3 COPD: Diagnosis Think about COPD in any patient with Dyspnea Progressive and persistent, worse with exertion Chronic cough and/or sputum production Associated risk factors Smoking, occupational, air pollution, infections, socioeconomic status No alternative explanation Spirometry is required to make the diagnosis AOA 2015 l October 20, 2015 l 3

4 COPD: Spirometry is required to make diagnosis FEV1/FVC < 0.70 or < LLN Use < LLN in elderly Fixed airflow obstruction Obtain spirometry on all patients with chronic cough, sputum production or dyspnea Spirometry is not recommended as screening tool Lung volumes, DLCO not necessary for diagnosis Hyperinflation (increase in TLC) Air trapping (increase in RV) Diffusion impairment (decrease in DLCO) Ann Inter Med: 2011; 155: AOA 2015 l October 20, 2015 l 4

5 Spirometry in COPD: Fixed airflow obstruction AOA 2015 l October 20, 2015 l 5

6 COPD and Smoking Majority of risk for developing COPD is from smoking 15 to 20% of smokers develop clinically significant COPD Symptoms typically develop after 20 or more pack years Smokers lose lung function at an accelerated rate Quitting is beneficial at any age, more pronounced in earlier quitters Passive smoke exposure has been implicated as a cause of COPD (affects women > men) Kohansal et al. Am J Respir Crit Care Med 2009;180:3 10 AOA 2015 l October 20, 2015 l 6

7 COPD in Never Smokers More common than you think Up to 20% of patients with COPD have never smoked Prior diagnosis of asthma More common in women moderate to severe obstruction Low BMI, low education level additional risk factors Occupational exposures: organic dust, biomass fuel Severe respiratory infections during childhood Chest 2011; 139(4): AOA 2015 l October 20, 2015 l 7

8 COPD: It s not all about airflow Comorbidities in COPD influence survival Agusti et al. Respiratory Research 2010; 11: 122. Divo et al. AJRCCM 2012; 186: AOA 2015 l October 20, 2015 l 8

9 Management of stable COPD Goals of treatment: Symptom reduction Improve exercise tolerance and health related QOL Prevent and treat complications and exacerbations Reduce hospitalizations and mortality Strategy: Education Smoking cessation Avoiding occupational/environmental exposures AOA 2015 l October 20, 2015 l 9

10 GOLD: Stepwise approach to COPD management 0: At Risk I: Mild II: Moderate III: Severe IV: Very Severe Avoidance of risk factor(s); influenza vaccination Add short-acting bronchodilator when needed Add regular treatment with one or more long-acting bronchodilators Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Add long-term oxygen if chronic respiratory failure Consider surgical treatments AOA 2015 l October 20, 2015 l 10

11 Pharmacologic management of stable COPD: Bronchodilators are the cornerstone Stepwise approach Improve symptoms and exercise tolerance Decrease exacerbations Reduce hospitalizations Most benefit from inhaled therapies is seen in patients with respiratory symptoms and FEV1 < 60% Monotherapy: strong recommendation Combination therapy: weak recommendation Both have moderate quality evidence Ann Inter Med: 2011; 155: AOA 2015 l October 20, 2015 l 11

12 Pharmacologic management of stable COPD When to think about inhaled steroids: Repeated exacerbations Repeated courses of oral steroids Response to inhaled steroids In combination with LABA ICS/LABA combination: Reduce rate of exacerbations Reduce rate of FEV1 decline Reduce airway hyper reactivity and symptoms Trend toward improved survival (TORCH 2007) AOA 2015 l October 20, 2015 l 12

13 Management of COPD: newer agents Aclidinium bromide (Tudorza Pressair ) LAMA, 400 mcg twice daily Fuhr et al. CHEST 2012; 141(3): Compared to tiotropium: similar efficacy and safety Roflumilast (Daliresp ) Phosphodiesterase 4 inhibitor, 500 mcg once daily oral Approved for severe COPD, reduces rate of exacerbations Criticism: pivotal studies excluded beneficial drugs Side effect profile: nearly 20% of patients discontinued the drug (main reason: diarrhea) AOA 2015 l October 20, 2015 l 13

14 Management of COPD: newer agents LABA/LAMA fixed dose combinations Umeclidinium/vilanterol (Anoro Ellipta ), once daily Rx Guidelines: try LABA/LAMA for patients who remain symptomatic and/or have exacerbations despite monotherapy Rodrigo et al. CHEST 2015; 148(2): Good safety profile Improvement in FEV1 (MCID 100 ml) > tiotropium Advantages over Tiotropium (Spiriva ) are unclear? Benefit in adherence (once daily, one inhaler) AOA 2015 l October 20, 2015 l 14

15 Management of COPD: newer agents Fluticasone Furoate/Vilanterol (Breo Ellipta ) Once daily ICS/LABA Tiotropium bromide/olodaterol (Spiolto Respimat ) Once daily LAMA/LABA AOA 2015 l October 20, 2015 l 15

16 Management of COPD: Long Term Oxygen AOA 2015 l October 20, 2015 l 16

17 Management of COPD: Pulmonary Rehab Reduces perceived intensity of breathlessness Improved exercise tolerance Reduction in hospitalization and length of stay Symptoms and disability should guide referral What your patients should expect: Exercise training (treadmill, low weights, bike) Education (nutrition and behavior modification) Inspiratory muscle training Average commitment: Three sessions/week Eight weeks Presentation Title l October 20, 2015 l 17

18 Management of COPD: How to impact survival Oxygen therapy Room air PaO2 55 or SaO2 88% Minimum of 15 hours per day Who to test: severe disease (FEV1 < 50%) Smoking cessation Non invasive ventilation Hospitalized for exacerbation Lung volume reduction Low baseline exercise tolerance, upper lobe disease AOA 2015 l October 20, 2015 l 18

19 COPD Management: Bottom Line Bronchodilators are central to management LABA, LAMA maintenance medication Add ICS if severe disease Increased symptom burden Frequent exacerbations Severe airflow obstruction (FEV1 < 50%) Think about pulmonary rehab in all patients with moderate to severe disease Assess need for long term oxygen AOA 2015 l October 20, 2015 l 19

20 COPD: Exacerbations Infection is implied in up to 80% 50% viral 45% bacterial 5% atypical Universal: excessive inflammation Eradicate bacteria markedly reduce inflammatory response Patients with COPD exacerbation and 2 symptoms (increased dyspnea, increased sputum volume, change in sputum color) give an bio cs Anthonisen NR et al. Ann Intern Med 1987;106:196 Sethi S. Chest 2000;117:380S-385S AOA 2015 l October 20, 2015 l 20

21 COPD Exacerbations: Guide to antibiotic selection Anzueto A et al. Am J Med Sci 2010; 340(4): Used with permission courtesy of Dr. Aboussouan AOA 2015 l October 20, 2015 l 21

22 COPD exacerbations: dose and duration of steroids AOA 2015 l October 20, 2015 l 22

23 Prevention of exacerbations: macrolides AOA 2015 l October 20, 2015 l 23

24 Presentation Title l October 20, 2015 l 24

25 COPD: When to refer Disease onset at age < 40 Frequent exacerbations ( 2 or more/year) despite treatment Rapid progression Severe COPD: FEV1 < 50% predicted Patients requiring long term oxygen therapy Comorbidities: heart failure, lung cancer, bronchiectasis AOA 2015 l October 20, 2015 l 25

26 Asthma

27 Asthma: Diagnosis Think about asthma in patients with Episodic cough, breathlessness, chest tightness, wheezing Ask about triggers (allergies, smoke, strong odors, stress, exercise, changes/extremes in weather) Nocturnal symptoms can be the key to diagnosis Spirometry is supportive of, but not necessary for, the diagnosis AOA 2015 l October 20, 2015 l 27

28 Asthma Phenotypes/Cluster Analysis Asthma is a complex disease Early: extrinsic vs. intrinsic asthma Multiple phenotypes: variable natural history, severity, and treatment response Traditional asthma medications don t work in all patients High eosinophil count, IgE level, and exhaled nitric oxide linked to greater response to inhaled corticosteroids On the horizon: endotypes AOA 2015 l October 20, 2015 l 28

29 Moore et al. AJRCCM 2009; 181: AOA 2015 l October 20, 2015 l 29

30 Wenzel et al. AJRCCM 2015; 192: AOA 2015 l October 20, 2015 l 30

31 Asthma Management: what doesn t cost a lot Smoking cessation Avoidance of triggers Allergy assessment and allergy treatment Controlling the environment Removing carpets when able HIPA filter on vacuum as an alternative, vacuum weekly Dust mite pillow covers Wash sheets in hot water, minimum once a week AOA 2015 l October 20, 2015 l 31

32 Asthma Management: what doesn t cost a lot Increase delivery of drug into the lung Increased potency of inhaled steroids Reduction in oropharyngeal candidiasis Toogood et al. AJRCCM 1984; 129: AOA 2015 l October 20, 2015 l 32

33 Asthma Management: the big bucks Remember: these medications are (really) expensive! The technique is just as important as the medication Use a spacer Elderly: think about diskus or nebulized medications Assess barriers to adherence Twice daily Patient assistance programs AOA 2015 l October 20, 2015 l 33

34 Asthma management: anti inflammatory is the standard Inhaled steroids: fluticasone (Flovent ), budesonide (Pulmicort ), mometasone (Asmanex ) Short acting beta agonists (SABA): albuterol Long acting beta agonists (LABA): formoterol, salmeterol ICS/LABA combination therapy: budesonideformoterol (Symbicort ), fluticasone salmeterol (Advair ), mometasone formoterol (Dulera ) High dose ICS: Advair or Dulera AOA 2015 l October 20, 2015 l 34

35 Asthma Management: additional therapies Anti leukotrienes: Montelukast (Singulair ), Zafirlukast (Accolate ), Zileuton (Zyflo ) Biologic agents/monoclonal antibody: Omalizumab (Xolair ), Mepolizumab Long acting muscarinic antagonist (LAMA): Tiotropium (Spiriva ) AOA 2015 l October 20, 2015 l 35

36 What happens after step 6? Internal Medicine Grand Rounds l 36

37 >= 20 : well controlled : not well controlled 15 : very poorly controlled Asthma Control Test QualityMetric incorporated, Internal Medicine Grand Rounds l

38 Asthma Management: assess for comorbidities Upper airway disease: chronic rhinosinusitis, nasal polyposis Obstructive sleep apnea GERD (no role for treatment if patient asymptomatic) Paradoxical vocal fold motion (formally known as vocal cord dysfunction) Obesity Depression AOA 2015 l October 20, 2015 l 38

39 AOA 2015 l October 20, 2015 l 39

40 Paradoxical Vocal Fold Motion AOA 2015 l October 20, 2015 l 40

41 Severe asthma is a problem 5 to 10% of all asthmatics Greatest morbidity Consume the majority of health care costs Mainstay of asthma therapy: short and long acting beta agonists, corticosteroids, leukotriene receptor antagonists Reduce inflammation/narrowing of the airways by relaxing smooth muscle Not universally effective AOA 2015 l October 20, 2015 l 41

42 Bronchial Thermoplasty: thermal energy reduces smooth muscle thickness in airways Presentation Title l October 20, 2015 l 42

43 AOA 2015 l October 20, 2015 l 43

44 Bronchial Thermoplasty improves asthmarelated QOL Healthcare utilization events during the posttreatment period (12w-12mo) was also lower in the treatment group. Castro 2010 AJRCCM AOA 2015 l October 20, 2015 l 44

45 AIR 2: lower event rate sustained for 2 years Castro 2010 ACCP AOA 2015 l October 20, 2015 l 45

46 Grab Bag

47 Asthma COPD Overlap Syndrome (ACOS) Up to 24% of patients with COPD report history of asthma The distinction is important: more symptoms, increased rate of exacerbations, more likely hospitalized Younger, women men, higher BMI, fewer pack years of smoking, greater % African Americans Similar lung function, less emphysema on imaging Eur Respir J 2014; 44: AOA 2015 l October 20, 2015 l 47

48 Asthma COPD Overlap Syndrome (ACOS) Suggested criteria Previous/current history of asthma/allergies Marked bronchodilator response (>400 ml) IgE level > 100 Blood eosinophils > 5% Usual feature: age > 40 Treatment response is different Early initiation of inhaled corticosteroids is recommended Chest. 2015; doi: /chest AOA 2015 l October 20, 2015 l 48

49 A word on vaccinations.. For chronic lung disease and/or cigarette smokers: Pneumovax (PPSV23) for all Age 65 or older with no previous pneumococcal vaccinations: Give Prevnar (PCV13) first followed by Pneumovax one year later Pneumovax before age 65: give Prevnar at age 65 followed by Pneumovax one year later Age 65 or older with previous pneumococcal vaccination: Give Prevnar, wait at least one year after PPSV23 dose AOA 2015 l October 20, 2015 l 49

50 A word on vaccinations.. Asthma with long term systemic steroids: give Prevnar Influenza protects against all cause mortality in patients with COPD Schembri et al. Thorax 2009 AOA 2015 l October 20, 2015 l 50

51 Smoking: it s never to late to quit AOA 2015 l October 20, 2015 l 51

52 Electronic cigarettes AOA 2015 l October 20, 2015 l 52

53 The power of advertising Perceived as a tool to quit or reduce smoking Prevalence among teens is alarming: up to 13% (2014 data) AOA 2015 l October 20, 2015 l 53

54 Electronic cigarettes: concerns Normalization of smoking behavior Gateway to tobacco products No long term safety data Products are not regulated by the FDA Lack of evidence of harm safety One 5 ml cartridge = 100 mg nicotine One mg of nicotine in conventional cigarette ~ 30 puffs ATS statement: recommend products are restricted or banned until more information available if allowed need to be closely regulated as medicines or tobacco products AOA 2015 l October 20, 2015 l 54

55 AOA 2015 l October 20, 2015 l 55

56 AOA 2015 l October 20, 2015 l 56

57 Classifying asthma severity and initiating therapy in youth > 12 years of age and adults Components of Severity Impairment Normal FEV1/FVC 8-19 yr 85% yr 80% yr 75% yr 70% Risk Recommended Step for initiating Treatment Intermittent Classification of Asthma Severity Persistent Mild Moderate Severe Symptoms < 2 days/week > 2 days/week Daily Throughout the day Nighttime awakenings SABA use for symptom control Interference with normal activity Lung function FEV1 > 80% FEV1/FVC normal Exacerbations requiring oral corticosteroids < 2X /month 3-4 x/month > 1x /week but not nightly < 2 days/week > 2 days/week but not daily Daily Often 7x / week Several times per day None Minor limitation Some limitation Extremely limited FEV1 > 80% FEV1/FVC normal 0-1 / year > 2 / year FEV1 60%-80% FEV1/FVC reduced <5% FEV1 < 60% FEV1/FVC reduced > 5% Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time Relative annual risk of exacerbations may be related to FEV1 Step 1 Step 2 Step 3 Step 4 or 5 consider short course of oral steroids

58 Assessing asthma control and adjusting therapy in youth > 12 years of age and adults Classification of Asthma Control Components of Control Well Controlled Not well Controlled Very Poorly controlled Symptoms < 2 days/week > 2 days/week Throughout the day Nighttime awakenings < 2x /month 1-3 x /week > 4 x/week Impairment Interference with normal activity Short-acting beta-agonist use for Symptom control None Some limitation Extremely limited < 2 days/week > 2 days/week Several times per day FEV1 or peak flow >80% predicted 60-80% predicted < 60% predicted Validated questionnaires ATAQ ACQ ACT 0 <0.75 >20 17 > ? N/A <15 Risk Exacerbations requiring oral systemic corticosteroids Progressive loss of lung function Treatment-related adverse effects 0-1/year > 2/year Consider severity and interval since last exacerbation Evaluation requires long-term follow-up care Medication side effects can vary in intensity Recommended Action for Treatment Maintain current step; F/U 1-6 months to maintain control Step up 1 step and evaluate in 2-6 weeks Consider short course of oral corticosteroids, Step up 1-2 steps, F/U 2 wk