Chronic Obstructive Pulmonary Disease (COPD) October 9, 2016 Chicago, IL COPD (Chronic obstructive pulmonary disease) is a major cause of mortality and morbidity in the United States. Alarmingly, COPD recently became the third leading cause of death behind heart disease and cancer. Current estimates suggest that COPD costs the nation almost $50 billion annually in both direct and indirect health expenditures. While there are an increasing number of treatment options for managing patients with COPD; determining which treatments are appropriate for patients has become more complex. Recent evidence-based guidelines, from both the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and the COPD Foundation, have been developed to assist clinicians in their diagnosis of COPD and treatment decision making. Although these two guidelines provide broadly similar criteria for COPD diagnosis, their approaches to disease characterization differ, which ultimately may affect treatment strategies. With the right tools and critical decision making we can manage clinical risks and improve patient outcomes. Learning Objectives At the end of the presentation, participants should be able to: 1. Discuss Critical Decision Making to allow most appropriate management plan for COPD. 2. Elaborate on Key Indicators for Considering a Diagnosis of COPD. 3. Describe the subtle differences between the GOLD and COPD Foundation guidelines. Kayur V. Patel, MD, MRO, FACP, FACPE, FACHE, FACEP Chief Medical Officer Access2MD
Disclosures I have no relevant financial relationships to disclose in regard to the content of this presentation Current Chief Medical Officer, Access2MD Associate Professor, IU School of Medicine Past 1.Director, Health Care Excel 2.CMO, Terre Haute Regional Hospital 3.Regional Medical Director, Team Health 4.Senior Vice President, Team Health Midwest 5.Regional Medical Director, Team Health Midwest 6.Clinical Instructor : a) Kaplan, NY b) Indiana School of Medicine Residency Program
Risk Factors Genes Infections Socio-economic status Aging Populations 9/2/2016
COPD is a Multisystem Disease Lung Cancer Anxiety, Depression, Addiction Cardiovascular Disease Anemia Peripheral Muscle Wasting & Dysfunction Osteoporosis Peptic Ulcers GI Complications Cachexia
COPD Comorbidities
Under-Treatment of COPD
Diagnostic Criteria What is the diagnostic criteria for COPD COPD is characterized by airflow limitation that is not fully reversible and is usually progressive. A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and a history of tobacco smoking. The diagnosis of COPD requires demonstration by spirometry of airflow limitation that is not fully reversible, in addition to symptoms of dyspnea and cough and exposure to risk factors for the disease such as smoking..
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2015 In patients with FEV1/FVC < 0.70: Gold 1 Mild FEV1 80% predicted Gold 2 Moderate 50% FEV1 < 80% predicted Gold 3 Severe 30% FEV1 < 50% predicted Gold 4 Very Severe FEV1 < 30% predicted 2016 In patients with FEV1/FVC < 0.70: Gold 1 Mild FEV1 80% predicted Gold 2 Moderate 50% FEV1 < 80% predicted Gold 3 Severe 30% FEV1 < 50% predicted Gold 4 Very Severe FEV1 < 30% predicted
Key Indicators for Considering a Diagnosis of COPD GOLD Report COPD Foundation Guide Spirometry indicated if: Any category below is present in a patient ages >40 years Dyspnea that is: Progressive, persistent, and worsens with exercise Spirometry indicated if: Symptoms of dyspnea, chronic cough/sputum are present Dyspnea that is: Troubling to the patient Chronic cough that is: Intermittent and unproductive Chronic sputum production: Any pattern may indicate COPD Chronic cough that is: Troubling to the patient Chronic sputum production that is: Troubling to the patient History of exposure to risk factors: Tobacco smoke, smoke from home cooking and heating fuels, occupational dusts, and chemicals Spirometry should also be considered if risk factors and 1 comorbidities are present: Risk factors: Smoking or other exposures, asthma history, childhood infections, prematurity, family history Comorbidities (including but not limited to): Heart disease, metabolic syndrome, osteoporosis, sleep apnea, depression, lung cancer, premature skin wrinkling
Comparison of GOLD and COPD Foundation Spirometric Classifications of Severity
Risk Factors 1. Mild FEV1 80% predicted 2. Moderate 50% FEV1 < 80% predicted 3. Symptoms: Less Symptoms (mmrc 0-1 or CAT < 10): patient is (A) or (C) 4. Airflow Limitation: Low Risk (GOLD 1 or 2): patient is (A) or (B) 5. Low Risk: 1 per year and no hospitalization for exacerbation: patient is (A) or (B) Classification of Severity of Airflow Limitation in COPD (Based on Post-Bronchodilator FEV1)
I: Mild FEV 1 /FVC < 0.70 FEV 1 80% predicted II: Moderate FEV 1 /FVC < 0.70 50% FEV 1 < 80% predicted GOLD Guidelines Pre-2013 III: Severe FEV 1 /FVC < 0.70 30% FEV 1 < 50% predicted IV: Very Severe FEV 1 /FVC < 0.70 FEV 1 < 30% predicted or FEV 1 < 50% predicted plus chronic respiratory failure Active reduction of risk factor(s); smoking cessation, flu vaccination Add short-acting bronchodilator (as needed) Add regular treatment with long-acting bronchodilators; Begin Pulmonary Rehabilitation Add inhaled glucocorticosteroids if repeated acute exacerbations Add LTOT for chronic hypoxemia. Consider surgical options
I: Mild FEV 1 /FVC < 0.70 FEV1 80% predicted II: Moderate FEV 1 /FVC < 0.70 50% FEV 1 < 80% predicted GOLD Guidelines 2016 III: Severe FEV 1 /FVC < 0.70 30% FEV 1 < 50% predicted IV: Very Severe FEV 1 /FVC < 0.70 FEV 1 < 30% predicted Active reduction of risk factor(s); smoking cessation, Elimination of Occupational Exposure, Benefit from Physical Activity Add long-acting bronchodilator (as needed) Add regular treatment with long-acting bronchodilators; Begin Pulmonary Rehabilitation Add inhaled glucocorticosteroids if repeated acute exacerbations Add LTOT for chronic hypoxemia. Consider surgical options
Risk Factors 1. Severe 30% FEV1 < 50% predicted 2. Very Severe FEV1 < 30% predicted 3. More Symptoms (mmrc 2 or CAT 10): patient is (B) or (D) 4. Airflow Limitation: High Risk (GOLD 3 or 4): patient is (C) or (D) 5. High Risk: 2 per year or 1 with hospitalization: patient is (C) or (D) Classification of Severity of Airflow Limitation in COPD (Based on Post-Bronchodilator FEV1)
1. Diagnostic approach Our Focus 2. Pretest probability and validity of test 3. Managing risks: on the foundation of evidence-based medicine
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9/2/2016 California Society of Health Systems Pharmacists
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