Ipswich and East CCG Asthma and COPD Guidelines

1. Ipswich and East CCGAsthma and COPD Guidelines Jonathan Douse Ipswich Hospital

2. How were guidelines developed? • Review of guidance • Reasoning behind decision making • Discussion of controversial issues!

3. How were guidelines developed? • Meeting of primary care and secondary care • Pharmacists • Physicians

4. How were guidelines developed? • Aim for guidance to be: • Not just about medication • Evidence based • Logical • Drugs only used within licence • Allow choice of device (within reason) • Patients must be able to take medication • Consistent between primary and secondary care • Cost effective

5. Review of evidence • Asthma • Latest BTS guideline (2012) • COPD • Latest NICE guideline (2010) CG 101 • West Suffolk CCG guidelines • Cost of medication • To primary and secondary care

6. Asthma guideline • For adults >18 • To support choice of new patients or patients needing stepping up or down • Patients stabilised on inhalers not in this guideline should not be switched unless deemed clinically appropriate and patients has had an asthma review.

7. Asthma Guideline (>18years) • Smoking cessation • Inhaler technique • Vaccination • Compliance with treatment • Annual review or earlier if symptoms don’t improve or worsen • Self management plan • Start at treatment step most appropriate to initial severity of asthma • Reconsider diagnosis if response to treatment unexpectedly poor.

8. Asthma Step 1 • Salbutamol • MDI • Easyhaler • Terbutaline • turbohaler

9. Controversy 1 • “Easy-Breath” inhaler device?

10. Step 2 • Add regular ICS • Quar 50Mcg 2 puffs BD (can decrease dose if controlled) • MDI • Autohaler • Budesonide • Easyhaler

11. Controversy 2 • Why Quar and not Clenil-Modulite?

12. Stepping up • Check: • Compliance • Technique • Trigger factors

13. Complete control of asthma • No daytime symptoms • No night time symptoms • No use of rescue medication • No exacerbations • No exercise limitation • Normal lung function

14. Step 3 (initial) • Add LABA using combination inhaler • Fostair 100/6 1 puffs BD • MDI • Fluitform 50/5 2 puffs BD • MDI • Symbicort 200/6 1 puff BD • turbohaler

15. Controversy 3 • Combination inhalers via separate inhalers • Why Fostair and Flutiform and not Seritide? • Why do none of the choices include Salmeterol?

16. Step 3 follow on • Benefit from LABA but inadequate response • Fostair 100/6 2 puffs BD • MDI • Flutiform 125/5 2 puffs BD • MDI • Symbicort 200/6 2 puffs BD • Turbohaler

17. Step 3 follow on • In selected patients consider • SMART • FMART

18. Step 3 follow on • No benefit from LABA • QUAR 100 2 puffs BD • MDI • Autohaler • Budesonide 200 puffs BD • easyhaler • Consider trail of montelucast or theophyline

19. Step 4 • Increase ICS up to BDP 2000mcg/day • Or addition of montelucast or theophyline • Seretide 500/50 1 puff BD • Accuhaler • Flutiform 250/10 2 puff BD • MDI • Symbicort 400/12 2 puffs BD • Tubohaler • Seretide 250/25 2 puffs BD MDI

20. Specialist referral • Poor response to asthma treatment/ uncontrolled at step 4. • Diagnosis is unclear • Unexpected findings • Prominent systemic features • Unexpected restrictive spirometry • Suspected occupational asthma • Monophonic wheeze or stridor • Chronic sputum production • Persistent non variable breathlessness • Marked eosinophila • Severe asthma exacerbation

21. COPD Guidance

22. COPD guideline • Smoking cessation • Pulmonary rehab • Vaccination • Review patients with mild to moderate COPD at least once per year and Very severe COPD at least twice per year • Self management plan

23. Short Acting B2 Agonist • Salbutamol (unlicenced!) • MDI • Easyhaler

24. If patient remains symptomatic • Check: • Compliance • Inhaler technique • Patient has stopped smoking

25. Long Acting B2 Agonist • Formoterol 12mcg 1puff BD • Easyhaler • Turbohaler

26. Controversy 4 • Why Formoterol and not Salmeterol or Indacaterol?

27. Long Acting Muscarinic Antagonist • Tiotropium 18mcg 1 capsule OD • Dry powder • Glycopyronnium bromide 44mcg • Dry powder

28. Controversy 5 • Tiotropium is more expensive than “Seebri Breezhaler” • Tiotropium Respimat?

29. Combination inhalers • Symbicort 200/6 2 puffs BD • Turbohaler • Seretide 500 1 puff BD • Accuhaler

30. Controversy 6 • Seretide 250 MDI via spacer? • Other combination inhalers? • Inhaled corticosteroids alone?

31. Pulmonary rehabilitation • MRC breathlessness grade 3 or above • www.copdsuffolk.com

32. Mucolytics

33. Oral Steroids • Not recommended • Patients who can’t be weaned of oral steroids should be referred to secondary care

34. Nebulisers

35. Oxygen • Consider in patients who are hypoxic SpO2 <92 and medically optimised • www.copdsuffolk.com

36. Exacerbations • Patients should have an emergency supply of antibiotics and steroids • Self management plan • Monitor the use of these drugs • Admission avoidance • www.copdsuffolk.com

37. End of life planning

38. Criteria for specialist advice • Referral for advice, investigation or treatment may be indicated at any stage of disease. • Not just those who are severely disabled

39. Criteria for specialist advice • Diagnostic uncertainty • Cor-pulmonale • Dysfunctional breathing • Bullous lung disease • Rapid decline in FEV1 • Haemoptysis • Symptoms disproportionate to lung function deficit

40. Criteria for specialist advice • Onset of symptoms under 40yrs or family history of alpha 1 antitrypsin deficiency • Assessment for oxygen, nebulisers or oral corticosteroids. • Assessment for lung volume reduction surgery or lung transplant.

41. Any questions?