COPD -Management of stable disease WONCA meeting Istanbul October 2015

Transcription

1 COPD -Management of stable disease WONCA meeting Istanbul October 2015 IPCRG 2007 Svein Høegh Henrichsen Oslo, Norway

2 Principles of management in stable COPD Patient education Smoking cessation Non-pharmacologic treatment Pharmacologic treatment Page 2 - IPCRG 2012

3 Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Key Points Smoking cessation has the greatest capacity to influence the natural history of COPD. Health care providers should encourage all patients who smoke to quit. None of the existing medications for COPD has been shown conclusively to modify the long-term decline in lung function. Influenza and pneumococcal vaccination should be offered depending on local guidelines. Page 3 - IPCRG Global Initiative for Chronic Obstructive Lung Disease

4 Patient education/ rehabilitation Patient involvement improves outcomes and adherence to treatment. o Reduce riskfactors = smoking cessation Quit smoking ASK- Advice on pharmacologic treatment ACT Flu vaccine and pneumococcal vaccine o Check device use (at each consultation) o Exacerbations when to act and how Written self-management plan (oral corticosteroids and antibiotics at home) o Physical activity Page 4 - IPCRG 2012

5 Average time work (minutes) Effect of pulmonary rehabilitation and bronchodilatation: rehabilitation * * Tiotropium n=47 32% 42% % Usual care n= n=91 *p<0, Weeks Page 6 - IPCRG 2012

6 Normal lungs COPD TLC IC IC TLC EILV IC 4 IC Inspiratory reserve volume Tidal volume Expiratory reserve volume 2 EILV 1 EELV EELV 3 Residual volume Exercise Exercise Page 8 - IPCRG 2012 Price D, Freeman D, Kaplan A, Østrem A, Reid J, van der Molen T. Primary Care Resp J. 2005;14:

7 Treatment options COPD according to GOLD guidelines 2015 Smoking cessation Flu vaccination Physical activity Pulmonary rehabilitation Patient group Non-pharmacologic treatment First choice Alternative choice A B C D Page 10 - IPCRG 2012 SAMA prn or SABA prn LAMA or LABA ICS + LABA or LAMA ICS + LABA and/or LAMA LAMA or LABA or SABA and SAMA LAMA and LABA LAMA and LABA or LAMA and PDE4-inh. or LABA and PDE4-inh. ICS + LABA and LAMA or ICS+LABA and PDE4- inh. or LAMA and LABA or LAMA and PDE4-inh.

8 Assess symptoms first few Symptoms C D A lot symptoms A B BMRC <2 CAT<10 CCQ<1 BMRC 2 CAT 10 CCQ 1 Page 11 - IPCRG 2012

9 A: few symptoms, low risk, mild disease Patient group First choice Alternative choice A SAMA prn or SABA prn LAMA or LABA or SABA and SAMA Long-acting inhaled bronchodilators are convenient and more effective for symptom relief than short-acting bronchodilators. Page 12 - IPCRG 2012

10 Assess risk next High Risk GOLD stage IV III C D Exacerbations 2 low Risk II I A B 1 0

11 B: More symptoms, low risk Patient group First choice Alternative choice B LAMA or LABA LAMA and LABA Long-acting inhaled bronchodilators reduce exacerbations and related hospitalizations and improve symptoms and health status. Combining bronchodilators of different pharmacological classes may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator. Page 14 - IPCRG 2012

12 C: more severe disease, few symptoms high risk Patient group First choice Alternative choice C ICS + LABA or LAMA Bronchodilator medications are central to the symptomatic management of COPD LAMA and LABA or LAMA and PDE4-inh. or LABA and PDE4-inh. Regular treatment with inhaled corticosteroids improves symptoms, lung function and quality of life and reduces frequency of exacerbations for COPD patients with an FEV 1 < 60% predicted. Inhaled corticosteroid therapy is associated with an increased risk of pneumonia. Page 15 - IPCRG 2012

13 D: High risk,more symptoms Patient group First choice Alternative choice D ICS + LABA and/or LAMA ICS + LABA and LAMA or ICS+LABA and PDE4-inh. or LAMA and LABA or LAMA and PDE4-inh. An inhaled corticosteroid combined with a long-acting beta 2 - agonist is more effective than the individual components in improving lung function and health status and reducing exacerbations in moderate to very severe COPD. Addition of a long-acting beta 2 -agonist/inhaled glucorticosteroid combination to an anticholinergic (tiotropium) appears to provide additional benefits. Page 16 - IPCRG 2012

14 Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Phosphodiesterase-4 Inhibitors In patients with severe and very severe COPD (GOLD 3 and 4) and a history of exacerbations and chronic bronchitis, the phospodiesterase-4 inhibitor, roflumilast, reduces exacerbations treated with oral glucocorticosteroids. Page 17 - IPCRG Global Initiative for Chronic Obstructive Lung Disease

15 COPD Assesment: Co-morbidities COPD patients are at increased risk for: Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Diabetes Lung cancer These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately. Page 18 - IPCRG 2012

16 Exacerbations To many patients are still not diagnosed until they are admitted with severe respiratory problems - Many of them already have severe disease with a bad prognosis: 9% acute mortality is 9% 3 months mortality is 19% 1 year mortality after discharg is 36% 25% of all deaths in this group are in the ages under 65 years and are considered preventableår Nanna Eriksen et al: Ugeskrift for Læger 2003; 165: Svein Høegh Henrichsen Norwegian College of General Practitionners Working Group on Respiratory Diseases

17 How do we diagnose exacerbations? Svein Høegh Henrichsen AIMEF BARI IPCRG 2007

18 What is an acute COPD exacerbation? o A sustained worsening of the patient's condition, from the stable state and beyond normal day-to-day variations, that is acute in onset and necessitates a change in regular medication in a patient with underlying COPD Page 21 - IPCRG 2012

19 Probability of surviving Worse Prognosis in Frequent Exacerbators 3 acute exacerbations requiring hospitalisation is associated with a risk of death 4.30 times greater than for those patients not requiring hospitalization 1.0 Group A Patients with no acute 0.8 A exacerbations 0.6 p< Group B B p=0.069 C p< Patients with 1 2 acute exacerbations of COPD requiring hospital management Group C Patients with 3 acute Time (months) exacerbations of COPD requiring hospital management Page 22 - IPCRG 2012 Soler-Cataluña et al. Thorax 2005; 60:

20 Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: Treatment Options Oxygen: titrate to improve the patient s hypoxemia with a target saturation of 88-92%. Bronchodilators: Short-acting inhaled beta 2 -agonists with or without short-acting anticholinergics are preferred. Systemic Corticosteroids: Shorten recovery time, improve lung function (FEV 1 ) and arterial hypoxemia (PaO 2 ), and reduce the risk of early relapse, treatment failure, and length of hospital stay. A dose of 40 mg prednisone per day for 5 days is recommended. Page 23 - IPCRG Global Initiative for Chronic Obstructive Lung Disease

21 Should we use antibiotics? Page 24 - IPCRG 2012

22 Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: Treatment Options Antibiotics should be given to patients with: Three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence. With increased crp-values/signs of bacterial infection Who require mechanical ventilation. Page 25 - IPCRG Global Initiative for Chronic Obstructive Lung Disease

23 Increasing severity Management of COPD Exacerbations Patient use of custom action plan Increase in dose/frequency of inhaled bronchodilators Systemic corticosteroids Antibiotics (if change in sputum) Prevent and treat respiratory failure Oxygen (low concentrations to prevent hypercapnia) Follow-up visit hours Consider BIPAP Consideration and management of comorbidities Consider appropriate exacerbation prevention strategies Page 26 - IPCRG 2012 Adapted from Hurst and Wedzicha. BMC Medicine 2009; 7:40. 2

24 Patient Action Plans Action plans are designed to 2,3 o o o Help patients recognise a deterioration in their symptoms Initiate changes to treatment early Reduce the impact of the exacerbation Developed in partnership with patients and caregivers to provide guidance for handling exacerbations 3,4 Regular respiratory medication and actions to remain stable Symptom recognition and actions to manage exacerbations A list of contacts Actions for symptom worsening or dangerous situations Page 27 - IPCRG

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26 Page 29 - IPCRG 2012 Thank you for your attention!