COPD GUIDELINES

1. COPD GUIDELINES Sarah Cowdell

2. 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

3. WHATS GOING ON • 2010 NICE update ( Gold Guidance) • COPD STRATEGY • NICE QUALITY INDICATORS • Oxygen suppliers reprocurement • New HOOF /HOCF • New Drugs • Community COPD service • Community referral pulmonary rehabilitation. • ESD • Decomissioned OP secondary care work

4. Wakefield and KirkleesCOPD Guidance • Diagnosis of COPD • Management of Stable Disease • Treatment of Acute Exacerbations • Taken from the NICE (2004)2010 update

5. 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.

9. 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

10. Severity

11. 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 Offer therapy Persistent exacerbations or breathlessness Consider therapy

12. Thorax February 2011; 66:93-96

13. Cost implications

14. 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 Other therapies

15. 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 Summary

16. Other stuff n.b presence of haemoptysis in a newly diagnosed or otherwise stable pt require urgent fast track referral • Chest x-ray • FBC/U&E • BMI • MRC score/Ex tolerance • Smoking status • Infection frequency • Vaccination • PLAN • Treatment level • Disease Info • SMOKING CESSATION • Review frequency • Self-management • Pulmonary rehabilitation

19. CAT COPD assessment test • 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) • Smoking cessation • Annual flu vaccination • Reduce exposure to exacerbation risk factors • Therapy as warranted by further clinical assessment • Score 10-20 (medium) • Review maintenance therapy • Referral for pulmonary rehabilitation • Best approaches to minimizing and managing exacerbations • Review aggravating factors – is the patient still smoking? • Score >20 (high) • Additional pharmacological treatments • Referral to pulmonary rehabilitation • Ensuring best approaches to minimising and managing exacerbations • Score >30 (very high) • In addition to the guidance for patients with low and medium impact CAT scores consider: • Referral to specialist care

21. 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

22. Paddock Jubilee Centre Twice weekly for 8 weeks Structured exercise programme Education component MRC score of ≥ 3 Transport cannot be provided Pulmonary rehabilitation

24. 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

25. EXACERBATIONS • A SUSTAINED WORSENING (+ 24 hours) OF SYMPTOMS REQUIRING A CHANGE IN TREATMENT • 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

28. Reducing mortality

29. Exacerbationsand mortality

30. GLOW3: Seebri significantly improved exercise tolerance on Days 1 and 21 against placebo 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 0 Day 21 Day 1 SBH12-C038 Date of Prep October 2012 Beeh KM et al. International Journal of COPD, 2012;7 5013-513

31. INDERCATEROL = ONBREZ GLYCOPYRRONIUM BROMIDE = SEEBREE ACLIDINIUM = What’s New?

32. Indercaterol - once daily long acting beta2 agonist Dry powder device

33. GLYCOPYRRONIUM BROMIDE Once daily long acting anti muscarinic MUSCARINIC

34. Twice daily long acting antimuscarinic Novel inhaler device Aclidinium

35. Roflumilast • Anti-inflammatory, reduces exacerbations • Not approved by NICE • £37.71

36. Anti-inflammatories? Exacerbation reduction Disease progression? More combinations of current molecules Once daily triple therapy in 1 inhaler? The future?

37. http://ckw.wdpct.nhs.uk/documents/long-term-conditions/