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Sandra G. Adams, MD, MS Pulmonary Diseases / Critical Care Medicine

Sandra G. Adams, MD, MS Pulmonary Diseases / Critical Care Medicine University of Texas Health Science Center at San Antonio South Texas Veterans Healthcare System. Risk. High. GOLD Assessment. Worse obstruction. IV: Very Severe FEV 1 <30% . III: Severe FEV 1 30% to 49%.

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Sandra G. Adams, MD, MS Pulmonary Diseases / Critical Care Medicine

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  1. Sandra G. Adams, MD, MS Pulmonary Diseases / Critical Care Medicine University of Texas Health Science Center at San Antonio South Texas Veterans Healthcare System

  2. Risk High GOLD Assessment Worse obstruction IV: Very Severe FEV1 <30% III: Severe FEV1 30% to49% Severity of Obstruction Post-bronchodilator FEV1/FVC <70% II: Moderate FEV1 50% to79% I: Mild FEV1 ≥80% FEV1 = Forced expiratory volume in one second; FVC = Forced vital capacity Global initiative for chronic obstructive lung disease. GOLD Website.http://www.goldcopd.com. Updated December 2011

  3. Modified Medical Research Council (MMRC) Dyspnea Scale Global initiative for chronic obstructive lung disease. GOLD Website.http://www.goldcopd.com. Updated December 2011

  4. Risk High GOLD Assessment Worse obstruction IV: Very Severe FEV1 <30% III: Severe FEV1 30% to49% Severity of Obstruction Post-bronchodilator FEV1/FVC <70% II: Moderate FEV1 50% to79% I: Mild FEV1 ≥80% High Modified Medical Research Council Dyspnea Score More severe 0 1 2 3 4 Risk Symptoms GOLD Website.http://www.goldcopd.com. Updated December 2011

  5. Risk Risk High High GOLD Assessment Worse obstruction Frequent exacerbations IV: Very Severe FEV1 <30% ≥ 2 or more per year ⌘See below III: Severe FEV1 30% to49% Severity of Obstruction Post-bronchodilator FEV1/FVC <70% Exacerbations II: Moderate FEV1 50% to79% 1 per year I: Mild FEV1 ≥80% None High Modified Medical Research Council Dyspnea Score More severe 0 1 2 3 4 Risk Symptoms Symptoms GOLD Website.http://www.goldcopd.com. Updated December 2011 ⌘May consider “high risk” if develops 1 severe exacerbation or has been hospitalized for exacerbation (not part of GOLD report)

  6. Risk Risk High High GOLD Assessment Worse obstruction Frequent exacerbations IV: Very Severe FEV1 <30% ≥ 2 or more per year⌘ III: Severe FEV1 30% to49% Severity of Obstruction Post-bronchodilator FEV1/FVC <70% Exacerbations A Mild-Mod Obstruction Minimal Symptoms Few Exacerbations II: Moderate FEV1 50% to79% 1 per year I: Mild FEV1 ≥80% None High Modified Medical Research Council Dyspnea Score More severe 0 1 2 3 4 Risk Symptoms GOLD Website.http://www.goldcopd.com. Updated December 2011

  7. Risk Risk High High GOLD Assessment Worse obstruction Frequent exacerbations IV: Very Severe FEV1 <30% ≥ 2 or more per year⌘ III: Severe FEV1 30% to49% Severity of Obstruction Post-bronchodilator FEV1/FVC <70% Exacerbations B Mild-Mod Obstruction Severe Symptoms Few Exacerbations A Mild-Mod Obstruction Minimal Symptoms Few Exacerbations II: Moderate FEV1 50% to79% 1 per year I: Mild FEV1 ≥80% None High Modified Medical Research Council Dyspnea Score More severe 0 1 2 3 4 Risk Symptoms GOLD Website.http://www.goldcopd.com. Updated December 2011

  8. Risk Risk High High GOLD Assessment Worse obstruction Frequent exacerbations IV: Very Severe FEV1 <30% C Severe Obstruction Minimal Symptoms ++ Exacerbations ≥ 2 or more per year⌘ III: Severe FEV1 30% to49% Severity of Obstruction Post-bronchodilator FEV1/FVC <70% Exacerbations B Mild-Mod Obstruction Severe Symptoms Few Exacerbations A Mild-Mod Obstruction Minimal Symptoms Few Exacerbations II: Moderate FEV1 50% to79% 1 per year I: Mild FEV1 ≥80% None High Modified Medical Research Council Dyspnea Score More severe 0 1 2 3 4 Risk Symptoms GOLD Website.http://www.goldcopd.com. Updated December 2011

  9. Risk Risk High High GOLD Assessment Worse obstruction Frequent exacerbations IV: Very Severe FEV1 <30% C Severe Obstruction Minimal Symptoms ++ Exacerbations D Severe Obstruction Severe Symptoms ++ Exacerbations ≥ 2 or more per year⌘ III: Severe FEV1 30% to49% Severity of Obstruction Post-bronchodilator FEV1/FVC <70% Exacerbations B Mild-Mod Obstruction Severe Symptoms Few Exacerbations A Mild-Mod Obstruction Minimal Symptoms Few Exacerbations II: Moderate FEV1 50% to79% 1 per year I: Mild FEV1 ≥80% None High Modified Medical Research Council Dyspnea Score More severe 0 1 2 3 4 Risk Symptoms GOLD Website.http://www.goldcopd.com. Updated December 2011

  10. Risk Risk High High GOLD Assessment Worse obstruction Frequent exacerbations C Severe Obstruction Minimal Symptoms ++ Exacerbations D Severe Obstruction Severe Symptoms ++ Exacerbations Severity of Airflow Obstruction Exacerbations B Mild-Mod Obstruction Severe Symptoms Few Exacerbations A Mild-Mod Obstruction Minimal Symptoms Few Exacerbations High Symptoms More severe Risk GOLD Website.http://www.goldcopd.com. Updated December 2011

  11. Management: GOLD Overview A B C D Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( ≥2/yr) Stage: Severe-Very Severe Severe Symptoms Exacerbations (≥2/yr) Active reduction of risk factors and administer vaccinations (influenza/pneumococcal) Increase physical activity Add short-acting bronchodilator (as needed) Add one or more long-acting bronchodilator(s): scheduled Add pulmonary rehabilitation Consider adding inhaled corticosteroid*** Consider PDE4-inhibitor PDE4-inhibitor = phosphodiesterase4 inhibitor ***Never use an inhaled corticosteroid as a single agent in patients with COPD (inhaled corticosteroids are not approved by the FDA as a single agent for COPD and they should always be prescribed with a long-acting bronchodilator) GOLD Website.http://www.goldcopd.com. Updated December 2011

  12. Pharmacotherapy: Overview A B C D Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( ≥2/yr) Stage: Severe-Very Severe Severe Symptoms Exacerbations (≥2/yr) Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid*** Consider PDE4-inhibitor PDE4-inhibitor = phosphodiesterase4 inhibitor ***Never use an inhaled corticosteroid as a single agent in patients with COPD (inhaled corticosteroids are not approved by the FDA as a single agent for COPD and they should always be prescribed with a long-acting bronchodilator) GOLD Website.http://www.goldcopd.com. Updated December 2011

  13. First Choice Pharmacotherapy A B C D Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) SABA (prn) Albuterol: ProAir® Proventil® Reli-On® Ventolin® Levalbuterol: Xopenex® Pirbuterol: Maxair® OR SAMA (prn) Ipratropium: Atrovent® Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( ≥2/yr) Stage: Severe-Very Severe Severe Symptoms Exacerbations (≥2/yr) Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor SABA = short-acting beta2-agonist SAMA = short-acting muscarinic antagonist (anticholinergic) GOLD Website.http://www.goldcopd.com. Updated December 2011

  14. First Choice Pharmacotherapy A B C D Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) SABA or SAMA (prn) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) LABA (scheduled) Arformoterol: Brovana® Formoterol: Foradil® Perforomist® Indacaterol: Arcapta® Salmeterol: Serevent® OR LAMA (scheduled) Tiotropium: Spiriva® Stage: Severe-Very Severe Minimal Symptoms Exacerbations( ≥2/yr) Stage: Severe-Very Severe Severe Symptoms Exacerbations (≥2/yr) Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor LABA = long-acting beta2-agonist LAMA = long-acting muscarinic antagonist (anticholinergic) GOLD Website.http://www.goldcopd.com. Updated December 2011

  15. First Choice Pharmacotherapy A B C D Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) SABA or SAMA (prn) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) LABA or LAMA (scheduled) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( ≥2/yr) ICS/LABA* Budesonide/Formoterol (Symbicort®) Fluticasone/Salmeterol (Advair®) OR LAMA Tiotropium (Spiriva®) Stage: Severe-Very Severe Severe Symptoms Exacerbations (≥2/yr) Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor ICS = inhaled corticosteroid LABA = long-acting beta2-agonist LAMA = long-acting muscarinic antagonist (anticholinergic) *Mometasone/Formoterol (Dulera®) is another ICS/LABA agent available in the US, but is not yet FDA-approved for COPD GOLD Website.http://www.goldcopd.com. Updated December 2011

  16. First Choice Pharmacotherapy A B C D Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) SABA or SAMA (prn) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) LABA or LAMA (scheduled) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( ≥2/yr) ICS/LABA or LAMA (scheduled) Stage: Severe-Very Severe Severe Symptoms Exacerbations (≥2/yr) ICS/LABA or LAMA (scheduled) Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor ICS = inhaled corticosteroid LABA = long-acting beta2-agonist LAMA = long-acting muscarinic antagonist (anticholinergic) GOLD Website.http://www.goldcopd.com. Updated December 2011

  17. Pharmacotherapy (Second Choice) A B C D Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) First choice: SABA or SAMA (prn) Second choice: SABA + SAMA (scheduled) or LABA or LAMA (scheduled) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) First choice: LABA or LAMA (scheduled) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( ≥2/yr) First choice: ICS/LABA or LAMA (scheduled) Stage: Severe-Very Severe Severe Symptoms Exacerbations (≥2/yr) First Choice: ICS/LABA or LAMA (scheduled) Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor GOLD Website.http://www.goldcopd.com. Updated December 2011

  18. Pharmacotherapy (Second Choice) A B C D Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) First choice: SABA or SAMA (prn) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) First choice: LABA or LAMA Second choice: LABA + LAMA Stage: Severe-Very Severe Minimal Symptoms Exacerbations( ≥2/yr) First choice: ICS/LABA or LAMA Stage: Severe-Very Severe Severe Symptoms Exacerbations (≥2/yr) First Choice: ICS/LABA or LAMA Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor GOLD Website.http://www.goldcopd.com. Updated December 2011

  19. Pharmacotherapy (Second Choice) A B C D Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) First choice: SABA or SAMA (prn) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) First choice: LABA or LAMA Stage: Severe-Very Severe Minimal Symptoms Exacerbations( ≥2/yr) First choice: ICS/LABA or LAMA Second choice: LABA + LAMA or ICS + LAMA Stage: Severe-Very Severe Severe Symptoms Exacerbations (≥2/yr) First Choice: ICS/LABA or LAMA Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor GOLD Website.http://www.goldcopd.com. Updated December 2011

  20. Pharmacotherapy (Second Choice) A B C D Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) First choice: SABA or SAMA (prn) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) First choice: LABA or LAMA Stage: Severe-Very Severe Minimal Symptoms Exacerbations( ≥2/yr) First choice: ICS/LABA or LAMA Stage: Severe-Very Severe Severe Symptoms Exacerbations (≥2/yr) First Choice: ICS/LABA or LAMA Second choice: ICS/LABA + LAMA or ICS/LABA + PDE4-inh or LAMA + PDE4-inh Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor PDE4-inhibitor = phosphodiesterase4 inhibitor: Roflumilast (Daliresp®) GOLD Website.http://www.goldcopd.com. Updated December 2011

  21. Pharmacotherapy (1st & 2nd Choices) A B C D Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) First choice: SABA or SAMA (prn) Second choice: SABA + SAMA (scheduled) or LABA or LAMA (scheduled) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) First choice: LABA or LAMA Second choice: LABA + LAMA Stage: Severe-Very Severe Minimal Symptoms Exacerbations( ≥2/yr) First choice: ICS/LABA or LAMA Second choice: LABA + LAMA or ICS + LAMA Stage: Severe-Very Severe Severe Symptoms Exacerbations (≥2/yr) First Choice: ICS/LABA or LAMA Second choice: ICS/LABA + LAMA or ICS/LABA + PDE4-inh or LAMA + PDE4-inh Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor GOLD Website.http://www.goldcopd.com. Updated December 2011

  22. Pharmacotherapy (Summary) A B C D Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) First choice: SABA or SAMA (prn) Second choice: SABA + SAMA (scheduled) or LABA or LAMA (scheduled) Consider Theophylline Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) First choice: LABA or LAMA Second choice: LABA + LAMA Consider Theophylline Stage: Severe-Very Severe Minimal Symptoms Exacerbations( ≥2/yr) First choice: ICS/LABA or LAMA Second choice: LABA + LAMA or ICS + LAMA Consider PDE4-inh or Consider Theophylline Stage: Severe-Very Severe Severe Symptoms Exacerbations (≥2/yr) First Choice: ICS/LABA or LAMA Second choice: ICS/LABA + LAMA or ICS/LABA + PDE4-inh or LAMA + PDE4-inh Consider Theophylline Short-acting bronchodilator (prn) Long-acting bronchodilator(s): scheduled Consider adding inhaled corticosteroid Consider PDE4-inhibitor GOLD Website.http://www.goldcopd.com. Updated December 2011

  23. Non-pharmacological Management: GOLD Overview A B C D Stage: Mild-Moderate Minimal Symptoms Exacerbations (0-1/yr) Stage: Mild-Moderate Severe symptoms Exacerbations (0-1/yr) Stage: Severe-Very Severe Minimal Symptoms Exacerbations( ≥2/yr) Stage: Severe-Very Severe Severe Symptoms Exacerbations (≥2/yr) Active reduction of risk factors Administer vaccinations (influenza/pneumococcal) Increase physical activity Add pulmonary rehabilitation Consider evaluation for need for supplemental oxygen Consider surgical eval GOLD Website.http://www.goldcopd.com. Updated December 2011

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