COPD GUIDELINES
Sarah Cowdell
WHY GUIDELINES MATTER
Predicted to be the third leading cause of death by 2030
Cause of over 30,000 deaths in the UK yearly
Chronically underdiagnosed – ( by up to 1/3 )
The cause of massive spend in healthcare resources (drugs, bed-days,
primary care consultations, workdays lost, comorbidities, mortality.
Impact on sufferers and their carers
WHATS GOING ON
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2010 NICE update ( Gold
Guidance)
COPD STRATEGY
NICE QUALITY INDICATORS
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Oxygen suppliers
reprocurement
New HOOF /HOCF
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New Drugs
• Community COPD
service
• Community referral
pulmonary
rehabilitation.
• ESD
• Decomissioned OP
secondary care work
Wakefield and Kirklees
COPD Guidance
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Diagnosis of COPD
Management of Stable Disease
Treatment of Acute Exacerbations
Taken from the NICE (2004)2010 update
Definition
Disease classified by airways obstruction which
is not reversible, is usually progressive and does
not vary from day today.
It will usually occur in smokers or ex smokers
over the age of 50.
Main symptoms include dyspnoea, cough and
sputum production.
• Airflow obstruction is defined as a reduction in
FEV1/FVC ratio <0.7
• No longer necessary to have FEV1 <80%
predicted for definition of airflow obstruction*
• If FEV1 is ≥ 80% a diagnosis of COPD should
only be made in the presence of respiratory
symptoms and/or reduced ratio.
• *post bronchodilator
Severity
Mild
Reduced FEV1/FVC, Normal FEV1
Moderate
FEV1 50-80%
Severe
FEV1 30-49%
Very severe
FEV1 <30%
Inhaled therapy
Breathless and/or exercise
limitation
SABA or SAMA as required*
FEV1 ≥ 50%
FEV1 < 50%
Exacerbations or
persistent
breathlessness
LABA
LAMA**
Offer LAMA in
preference to regular
SAMA four times a
day
LABA + ICS in a
combination inhaler
Consider LABA + LAMA
if ICS declined or not
tolerated
LAMA**
Offer LAMA in
preference to regular
SAMA four times a
day
LABA + ICS in a combination
inhaler
Consider LABA + LAMA if ICS
declined or not tolerated
LAMA + LABA + ICS
Persistent
exacerbations or
breathlessness
Offer
therapy
Consider therapy
Thorax February 2011; 66:93-96
Cost implications
Fometerol Turbohaler
Salmeterol MDI
Salmeterol Accuhaler
Symbicort Turbohaler
Seretide Accuhaler
Seretide MDI
Tiotropium Handihaler
Tiotropium Respimat
£23.75
£27.80
£29.26
£38.00
£40.92
£59.58
£34.87
£36.26
Other therapies
• Carbocisteine
– Reduce exacerbations if chronic sputum
production- £16.03
• Theophylline
– May improve breathless, may enhance action
of ICS- Approx £5.00
• Montelukast
– Not recommended for COPD
Summary
• Bronchodilators improve symptoms
• No clear benefit of 1 agent over another
• “Adding on” bronchodilators improves
symptoms further
• Adding on inhaled corticosteroids has a
small additional benefit
• Importance of the inhaler device
Other stuff n.b presence of haemoptysis in a newly diagnosed or
otherwise stable pt require urgent fast track referral
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Chest x-ray
FBC/U&E
BMI
MRC score/Ex
tolerance
• Smoking status
• Infection frequency
• Vaccination
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PLAN
Treatment level
Disease Info
SMOKING CESSATION
Review frequency
Self-management
Pulmonary
rehabilitation
CAT COPD assessment test
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The CAT provides a reliable measure of the impact of COPD on a patients health status
Score 5 – (upper limit of normal in healthy non-smokers)
Score <10 (low)
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Smoking cessation
Annual flu vaccination
Reduce exposure to exacerbation risk factors
Therapy as warranted by further clinical assessment
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Review maintenance therapy
Referral for pulmonary rehabilitation
Best approaches to minimizing and managing exacerbations
Review aggravating factors – is the patient still smoking?
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Additional pharmacological treatments
Referral to pulmonary rehabilitation
Ensuring best approaches to minimising and managing exacerbations
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In addition to the guidance for patients with low and medium impact CAT scores
consider:
Referral to specialist care
Score 10-20 (medium)
Score >20 (high)
Score >30 (very high)
»
Pulmonary Rehabilitation
• Offer to all patients who consider
themselves functionally disabled by COPD
• Make available to all appropriate people,
including those recently hospitalised from
an acute exacerbation [2010]
• Hold at times that suit patients and in
buildings with good access
Pulmonary rehabilitation
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Paddock Jubilee Centre
Twice weekly for 8 weeks
Structured exercise programme
Education component
MRC score of ≥ 3
Transport cannot be provided
12 months
before PR
12 months
after PR
Change
Admissions
9
7
-22%
Length of
stay (days)
8.5
5.1
-40%
Bed days
76.5
35.7
-53%
Managing exacerbations
• The frequency of exacerbations should be reduced by
appropriate use of inhaled corticosteroids and
bronchodilators
• Give self management advice on responding promptly
to symptoms of exacerbation.
• Start appropriate treatment with oral steroids and
antibiotics
• Use of hospital-at-home or assisted-discharge
schemes
• Use of NIV as indicated
EXACERBATIONS
• A SUSTAINED WORSENING (+ 24 hours) OF SYMPTOMS
REQUIRING A CHANGE IN TREATMENT
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CHANGE IN SPUTUM COLOUR
INCREASE IN COUGH
CHANGE IN VOLUME OF SPUTUM ( LESS OR MORE)
INCREASED BREATHLESSNESS OR TAKING LONGER THAN USUAL
TO RECOVER FROM USUAL ACTIVITY
Amoxicillin 500mg TDS 7 days
Prednisolone 30mg OD 7 days
Reducing mortality
Exacerbations
and mortality
GLOW3: Seebri significantly improved exercise tolerance
on Days 1 and 21 against placebo
600
Exercise endurance time (s)
Δ (95% CI):
88.9
(44.7,133.2)
seconds,
p<0.001
Δ (95% CI):
43.1
(10.9,75.4)
seconds,
p<0.001
500
400
300
0
Seebri 44 µg o.d. Placebo
Day 1
SBH12-C038 Date of Prep October 2012
Seebri 44 µg o.d. Placebo
Day 21
Beeh KM et al. International Journal of COPD, 2012;7 5013-513
What’s New?
• INDERCATEROL =
ONBREZ
• GLYCOPYRRONIUM BROMIDE = SEEBREE
• ACLIDINIUM =
Indercaterol - once daily long acting beta2 agonist
Dry powder device
GLYCOPYRRONIUM BROMIDE
Once daily long acting anti muscarinic
MUSCARINIC
Aclidinium
• Twice daily long acting antimuscarinic
• Novel inhaler device
Roflumilast
• Anti-inflammatory, reduces exacerbations
• Not approved by NICE
• £37.71
Moderate/severe
exacerbations
Use of systemic steroids
and/or antibiotics
Placebo
1.37
Roflumilast
1.14
(ARR -17%)
1.35
1.13
(ARR -16%)
The future?
• Anti-inflammatories?
– Exacerbation reduction
– Disease progression?
• More combinations of current molecules
– Once daily triple therapy in 1 inhaler?
http://ckw.wdpct.nhs.uk/documents/long-termconditions/