Co-morbiditeit associeert met respiratoire aandoeningen louter omwille van de leeftijd. COPD patiënten hebben veel meer kans op longkanker dan rokers

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1 Academisch centrum huisartsgeneeskunde Pneumologie Juni 2012 Prof W Janssens

2 Co-morbiditeit associeert met respiratoire aandoeningen louter omwille van de leeftijd. COPD patiënten hebben veel meer kans op longkanker dan rokers zonder COPD. Meer dan de helft van de COPD patiënten overlijdt ten gevolge van respiratoir falen. Comorbiditeit is de voornaamste hinderpaal voor revalidatie.

3 Prevalence in general pratice 21 praktijken in Canada 1000 consecutieve patiënten Fortin et al. An Fam Med 2005

4 Respiratory disease and comorbidity patiënten: 4% met chronische respiratoire ziekten O kelly et al. Resp Med 2011

5 COPD: airway inflammation 0 normal COPD 1 2 FEV 1 Liter 3 COPD 4 5 Normal Seconds

6 COPD: systemic inflammation Barnes et al. Eur Respir J 2009

7 COPD: systemic inflammation * * P<.05 versus other groups Pinto-Plata et al. Thorax. 2006

8 COPD and comorbidity Genetic background smoking pollutants ageing inactivity Lung disease Airway inflammation Spill-over Systemic inflammation Systemic consequences Co-existing diseases Comorbidities Barnes et al. Eur Respir J, 2009

9 COPD and comorbidity LUNG CANCER ANEMIA VASCULAR DISEASE DEPRESSION COPD CARDIAC DISEASE OSTEOPOROSIS MUSCULAR DISEASE DIABETES Agusti Proc Am Thorac Soc

10 Comorbidities: which and when? Evidencefromstudies

11 COPD and cardiovascular disease * * * * * * * Curkendall et al. Am J Epidemiol. 2006

12 COPD and ischemic heart disease P <0.001 Decreasing FEV 1 Hole et al. BMJ.1996

13 COPD and incident diabetes P<0.05 Rana et al. Diabetes Care

14 COPD and osteoporosis Prevalence of osteoporosis in COPD: 20-60% Lehouck et al. Chest 2011

15 COPD and osteoporosis Sin et al. Am J Med. 2003

16 COPD and depression Prevalence (%) * P< 0.05 * Depression Anxiety COPD (n= 1320) no COPD (n=18740)

17 COPD and cachexia * P< Sergi et al. Respir Med

18 COPD and cachexia 100 % 80 % 60 % BMI orffm BMI and FFM nml 40 % 20 % GOLD II GOLD III GOLD IV Schols et al. Am J Clin Nutr 2005

19 Lung cancer and COPD 50% Frequency (%) 40% 30% 20% 10% Lung cancer Smoking control <40% 40-60% 60-80% % % >120% FEV 1 Young et al ERJ 2008

20 Lung cancer and COPD COPD Healthy smoker 5 5 Cancer 1/4 in COPD getslungcancer 1/16 in non-copd group gets lung cancer RR = 4 Young et al ERJ 2008

21 Comorbidities: diseaseseverityand prognosis

22 Comorbidityand diseaseseverity Leuven COPD Cohort of smoking individuals COPD-related comorbidities: number ischemic age heart disease, stroke, peripheral vascular disease diabetes, osteoporosis, skeletal muscle weakness, anemia BMI pack-years FEV 1 (%) DLCO (%) Unpublished data

23 Comorbidityand diseaseseverity Leuven COPD Cohort: number of comorbidity increases with severity 3 or >3 comorbidities 2 comorbidities 1 comorbidities 0 comorbidity Unpublished data

24 Comorbidityand diseaseseverity Leuven COPD Cohort: Complaints determined by comorbidity CCQ score mmrc score 0 comorbidity Unpublished data

25 Comorbidityand phenotypes Leuven COPD Cohort: cluster analysis phenotypes and comorbidity PR Burgel et al. Submitted

26 Comorbidityand phenotypes % survival Phenotype 1 Phenotype 3 Phenotype Follow-up (years) PR Burgel et al. Submitted

27 Comorbidityand phenotypes Phenotype 2 Phenotype 3 % total number of deaths in each phenotype PR Burgel et al. Submitted

28 Comorbidityand mortality CHS: subjects 5 years follow-up Number of comorbidities (diabetes, hypertension, cardiovascular disease) Hazard ratio Mannino et al. ERJ 2008

29 Comorbidityand mortality TORCH: intervention study in 6112 patients with 3y follow-up All cause mortality (14,3%) 18% 21% 35% 27% Lung cancer Cardiovascular Respiratory Other Calverley et al. NEJM. 2007

30 Comorbidities: Impact of treatment

31 Impact of treatment Pharmacotherapy COPD comorbidities +? FEV1 Exacerbations Quality of life Dyspnea Exercise tolerance Pharmacotherapy

32 Pharmacotherapy Only indirect evidence, retrospective or post hoc analyses no randomised controlled trials B blokkers may reduce mortality and risk of exacerbations in patients with COPD. Rutten et al. Arch Intern Med Effect of B-blockers in treatment of COPD: a retrospective cohort study. Short et al. BMJ 2011 Impact of statins and ACE inhibotors on mortality after COPD exacerbations. Mortensen et al. Resp Research 2009 Reduction of morbidity and mortality by statins and ACE inhibitors in COPD. Mancini et al. J Am Coll Cardiol 2006

33 Rehabilitation ATS / ERS statement on pulmonary rehabilitation: Definition: Pulmonary rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, and reduce health care costs through stabilizing or reversing systemic manifestations of the disease. Nici et al. AJRCCM 2006

34 Pulmonary rehabilitation improves exercise capacity reduces dyspnea improves health-related quality of life reduces readmission and exacerbation Lacasse et al. Cochrane Review 2009 Puhan et al. Cochrane Review 2009

35 Impact of rehabilitation COPD comorbidities? + FEV1 Exacerbations Quality of life Dyspnea Exercise tolerance Pharmacotherapy Rehabilitation

36 Conclusion

37 Conclusion Rehabilitation

38 Co-morbiditeit associeert met respiratoire aandoeningen louter omwille van leeftijd. FOUT COPD patiënten hebben veel meer kans op longkanker dan rokers zonder COPD. JUIST Meer dan de helft van de COPD patiënten overlijdt ten gevolge van respiratoir falen. FOUT Comorbiditeit is de voornaamste hinderpaal voor revalidatie. FOUT