ASTHMA - COPD

Dr. Nino JN DoydoraSection of Pulmonary Medicine

ASTHMA - COPD

DisclosuresNovartis A 52-week Treatment, Multi-Center, Randomized, Double-Blind, Parallel-Group and active Controlled Study to

Evaluate the Effect of QVA149 (110/50 ug o.d.) vs NVA237 (50 ug o.d.) and Open Label Tiotropium (18 ug o.d.) on COPD exacerbations in Patients with Severe to very Severe COPD October 2010-October 2011

A 26-week Treatment, Multi-Center, Randomized, Double-Blind, Parallel-Group and active Controlled (open label) Study to assess the efficacy, safety and tolerability of QVA149 (110/50 ug o.d.) in Patients with Moderate to Severe COPD May–October 2011

Utsuka

Objectives:Review GINA 2014 guidelines on AsthmaReview the GOLD 2014 guidelines on COPD

EpidemiologyPathophysiologySigns and symptomsDiagnosis Treatment

Approach to a patient with ACOS (Asthma-COPD Overlap Syndrome) GINA 2014

CASE 119 year old female studentCC: 3 days cough, wheezing, SOB

Precipitated by exercise (frisbee)Relieved by salbutamol nebulization (past 3

nights)Self medicated with prednisone 10mg 1 dose

(+) history of asthma attacks during childhood(+) family Hx of asthma (mother)(+) Hx of atopy and (+) allergy to crustaceansPE: talks in sentences with occasional wheeze

Asthma

A reversible obstructive airway disease due to bronchial muscle constriction and airway inflammation; characterized by cough, wheezing and shortness of breath.

Resolves spontaneously or with use of rescue meds.Exacerbations are caused by triggers.

1 of 10 Filipino adults3 of 10 Filipino Children

ASTHMA – levels of controlCharacteristic Controlled Partly controlled Uncontrolled

Daytime symptoms: wheezing, cough, SOB

None >2x/week >3x/week

Limitation of activities none any anyNocturnal awakening none any anyNeed for reliever meds < 2x / wk >2x/wk >2x/week

ACT – ASTHMA CONTROL TEST

< 20 – suggests poor Asthma control

ACT – ASTHMA CONTROL TEST

< 20 – suggests poor Asthma control

DiagnosticsSpirometry – measures certain lung volumes; useful in diagnosing

obstructive lung patternsPeak flow – screening test; measures maximum speed of expiration

Peak flow

Patient’s Peak flow showed 65% from predicted

TreatmentNon-pharmacologic

Patient educationInhaler techniquePulmonary Rehabilitation Program

PharmacologicOral medicationsInhaled medications

Commonly used Inhaled treatments for Asthma & COPDCommonly used Inhaled treatments for Asthma & COPD

Short Acting BronchodilatorShort Acting B2 Agonist agent (SABA) = Salbutamol,

TerbutalineShort Acting Anti-Muscarinic agent (SAMA) = Ipratropium

Bromide

Long Acting BronchodilatorLong Acting B2 Agonist agent (LABA) = Salmeterol,

Formoterol, indacaterolLong Acting Anti-Muscarinic agent (LAMA) = Tioptropium

Inhaled Corticosteroid (ICS) = Fluticasone, Budesonide, beclomethasone

Combination: SABA + SAMA = Salbutamol + Ipratropium (Pulmodual)

Combination: LABA + ICS Salmeterol + Fluticasone (Adeflo) Formoterol + Budesonide

Treatment Patient education Inhaler technique and adherence to medications

STEP 1 STEP 2 STEP 3 STEP 4 STEP 5Preferred Controller Choice

NONE Low Dose ICS(Inhaled Steroid)

Low doseICS-LABA(ADEFLO)

Medium/HighICS-LABA(ADEFLO)

Refer for add on treatment

(anti-IgE)

Other ControllerOptions

-- LTRA or methylxanthines

(montileukastOr Theophylline)

Medium/HighICS-LABA OR

Low dose ICS/LABA + LTRA or /+ Theophylline

High DoseICS-LABA +

LTRA or Theophylline

Low dose oral steroid

RELIEVER SABA – short acting B2-agonist (Salbutamol)

Strategies to ensure effective use of inhaler devices

CHOOSEMost appropriate device

The medication neededAvailable devicesCostPatient skills and patient’s choice

Ensure no physical barriers, e.g. arthritisAvoid use of multiple different inhaler

types to avoid confusion

2014

Strategies to ensure effective use of inhaler devices

2014

Clinicians should be able to demonstrate correct technique for each of the inhalers they prescribe

For MDIs - use a spacer Improves deliveryReduces potential side-effects of ICS

Home meds and plans:Inhaled corticosteroid

May add oral steroid for 3-5 daysRound the clock reliever use for a few days then give on PRN basisIf symptoms worsen :

Follow-up in 3-5 days with chest X-rayAssess other possible causes of exacerbation

Follow-up 2 weeks – 1 month after consultMeasure peak flow on succeeding visits6-12 months of ICS therapy

Case 2:72 year old housewifeCC: on and off cough, wheezing, shortness of breath

Relieved by salbutamol nebulization lately is more bothersome after hosting a

birthday partywith grayish sputum, difficulty sleepingHas consulted several doctors; has 4 inhaler

devices Passive smokerPreviously hospitalized due to asthma 3 months agoPE: talks in phrases, (+) wheezing both lung fields

Case 2:

77 female smoker

Inhalers:•Tiotropium handihaler LAMA

•Salbutamol MDI SABA

•Procaterol swinghaler SABA

•Formoterol + Budesonide turbohaler ICS-LABA

•Budesonide turbohaler ICS

COPD: 2014 GOLD Definition

Pink Puffer

Blue Bloater

COPD

characterized by airflow limitation that is not fully reversible and is usually progressive

preventable and treatableexacerbations & co-morbidities contribute to the overall

severity © 2014 Global Initiative for Chronic Obstructive Lung Disease

CUASES of COPD

SMOKING1 pack/dayIn 10 years

PollutionExposure to Hazardous chemicals

Do we often see these COPD patients?

Pink Puffer

Blue Bloater

COPD prevalenceamong Filipinos > 40 yo:

20% 20% Idolor et al. Respirology 2012.

Mortality comparisons with COPD exacerbation and AMI

3

50

35

69

0 20 40 60 80

No Shock

Shock

Moderate

Severe

%

COPD Myocardial Infarction

Swedish Registry 2008, GUSTO-1 Trial 2007

How do we know they have COPD?

© 2014 Global Initiative for Chronic Obstructive Lung Disease

Acute exacerbation in COPDIncreased symptoms

Reduced lung function

Accelerate lung function decline

Deteriorate quality of life

Increased economic cost

Increased mortality

Impact of acute

exacerabations in COPD

“an acute event characterized by worsening of respiratory

symptoms that is beyond normal day-to-day variations and leads

to a change in medication.”

GOLD Strategy Document 2014 (http://www.goldcopd.org/)

© 2014 Global Initiative for Chronic Obstructive Lung Disease

Vicious Cycle of Inflammation-Oxidative Stress-Exacerbations in COPD

Oxidativestress

Anti-proteinase-Proteinase imbalance

COPD Pathology:

Exacerbations

• Cigarette smoke• Occupational dust & fumes• Biomass fuels

• Small airway fibrosis• Emphysema• Mucous hypersecretion

• Systemic manifestations

Modified British Medical Research Council (mMRC) Dyspnea Scale

COPD Assessment Test : CATI never cough I cough all the time                                                    

I have no phlegm (mucus) in my chest at all My chest is full of phlegm                                                    

My chest does not feel tight at all My chest feels very tight                                                    When I walk up a hill or one flight When I walk up a hill or one flight of stairs I am not breathless of stairs I am very breathless                                                    I am not limited doing any activities at home I am very limited doing activities at home                                                    I am confident leaving my home despite my I am not at all confident leaving my home lung condition because of my lung condition                                                    I sleep soundly I don't sleep soundly because of

my lung condition                                                    I have lots of energy I have no energy at all                                                

COPD Assessment Test : CATI never cough I cough all the time                                                    

I have no phlegm (mucus) in my chest at all My chest is full of phlegm                                                    

My chest does not feel tight at all My chest feels very tight                                                    When I walk up a hill or one flight When I walk up a hill or one flight of stairs I am not breathless of stairs I am very breathless                                                    I am not limited doing any activities at home I am very limited doing activities at home                                                    I am confident leaving my home despite my I am not at all confident leaving my home lung condition because of my lung condition                                                    I sleep soundly I don't sleep soundly because of

my lung condition                                                    I have lots of energy I have no energy at all                                                

SCORE: 35

COPD treatment: 2 MAIN GOALSGoals for treatment of stable COPD

Relieve symptomsImprove exercise toleranceImprove health statusAndPrevent disease progressionPrevent and treat exacerbationsReduce mortality

REDUCE SYMPTOM

S

REDUCE RISK

of exacerbation

Global Strategy for the Diagnosis, Management and Prevention of COPDGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2014

THERAPEUTIC OPTIONSWhat is the single most effective intervention to slow the progression of COPD?

1Home

Oxygen

2Pulmonary

Rehab.

3Smoking

Cessation

4Flu

Vaccination

Evidence A

How to start Treatment*Newly Diagnosed COPD PatientActive Reduction of Risk Factors

1. Smoking Cessation

2. Vaccination- Yearly Influenza ; Pneumococcal Vaccine every 5 years As Needed SABA or SABA/SAMA or if patient may benefit from OD/ bid treatment use

LABA or LAMA Assess : symptoms and RISK:

Pulmonary Rehabilitation Long Acting Bronchodilator

LABA alone (indacaterol) or LAMA alone (Tiotropium) Assess: More Symptoms low Exacerbation Risk

Add another Long acting bronchodilator LABA + LAMA or LAMA + LABA

Assess: More Symptoms, High Exacerbation Risk Progressive & Frequent Exacerbation

+ ICS LAMA + LABA + ICS

Adjunctive: Pulmonary rehabilitation, O2 treatment Surgical Options

•Based on Pharmacologic first choice treatment, GOLD 2011• other treatment options available.

ICS- inhaled steroid: fluticasone/budesonide/beclomethasone SABA – Salbutamol; SAMA – Ipatropium; LABA – Indacaterol; LAMA- Tiotropium SABA+SAMA – Salbu+IpBr (Pulmodual) OR *ICS+LABA – Fluticasone+Salmeterol (Adeflo)

Pharmacological Management of COPDPatien

tFirst Choice Second Choice Alternative Choice

ASABA or SAMA prn SABA and SAMA

LABA or LAMATheophylline (Option: Doxofylline )

BLABA or LAMA LABA and LAMA

SABA and /or SAMATheophylline (Option: Doxofylline )

CICS +LABA or LAMA LABA and LAMA

PDE4 InhibitorSABA and/ or SAMATheophylline(Option: Doxofylline )

DICS+ LABA and LAMA

ICS + LAMA ICS + LABA + LAMAICS and LABA and PDE 4 inhLABA + LAMALAMA + PDE 4 inh

CarbocisteineSABA and/ or SAMATheophylline(Option: Doxofylline )

PulmodualDilatair

Dilatair

Dilatair

Dilatair

Adeflo

Adeflo

GUIDED ASTHMA SELF-MANAGEMENT EDUCATION AND SKILLS TRAINING

Inhaler use is a skill - must be learned and maintainedUp to 70–80% are unable to use their inhaler

correctly. Unfortunately, many health care providers

are unable to correctly demonstrate how to use the inhalers they prescribe

Most people with incorrect technique are unaware that they have a problem

There is no ‘perfect’ inhaler - patients can have problems using any inhaler device

2014

Strategies to ensure effective use of inhaler devices

2014

Clinicians should be able to demonstrate correct technique for each of the inhalers they prescribe

For MDIs - use a spacer Improves deliveryReduces potential side-effects of ICS

Miat Monodose DPI

Twist

A New Twist to FDC ICS-LABA Inhaler Therapy

Passive DPI (aerolizer) breath actuated compact, portable, easy to

use no hand-mouth coordination

required Inhalation by capsule loaded by the

patient 40 capsules/ box Lactose carrier IFR > 60 lpm; no breath hold Protect from humidity

Sims MW. Chest 140(3):781–788, 2011.Laube BL, ERS/ISAM Task Force on Inhalational Therapy. Eur Respir J 37: 1308–1331, 2011.

Labris NR, Dolovich MB. Br J Clin Pharmacol 56: , 600–612, 2003.

50/250 mcg50/500 mcg

Salmeterol xinafoate/ Fluticasone propionate (Adeflo) via Adehaler

Dry Powder Inhaler

Dry Powder Inhaler

Wrong Right

Case 355 year old, male, teacherCC: cough, wheezing, shortness of breath 7 days

Precipitated by exposure to dust (he rides a motorbike)

Sneezing, itchy throatUnable to sleep due to SOB, partially relieved by

salbu neb(+) history of childhood asthma(+) 20 pack year (current) smoker(+) history of antibiotic (Co-amox) intake 4 weeks ago after diagnosed with

pneumonia as outpatient.PE: talks in sentences, (+) wheezing both lung fields

What will you give to this patient?A. SABA (Salbutamol PRN)B. ICS (Budesonide)C. LAMA (Tiotropium)D. LABA (Indacaterol)E. ICS+LABA (Fluticasone + Salmeterol)

ACOS (Asthma-COPD Overlap)

For a patient, count the number of checked boxes in each column. If 3 or more are checked for either asthma or COPD , that diagnosis is suggested. But if there are similar numbers of checked boxes in each column, ACOS should be considered.

ACOS (Asthma-COPD Overlap)

Spirometry:

ACOS (Asthma-COPD Overlap)

Approach to ACOS (Asthma-COPD Overlap Syndrome)

Asthma >> ICS (Inhaled corticosteroid)COPD >> LABA (long acting B2 agonist)ACOS >> ICS + LABA

Approach to ACOS (Asthma-COPD Overlap Syndrome)At least among adults, ACOS might represent a severe form of asthma,

characterized by greater risk of hospitalizations and exacerbationsACOS is likely the result of early asthma that has progressed to fixed

airway obstruction because airway remodeling and of its interaction with smoking

Treatment may prevent a steeper decline of lung function among ACOS.

De Marie Et. Al. ERS 2013 Presentation

Patient Education

SMOKER'S PRAYER

Heavenly Father, hear my plea,        and grant my lungs serenity.

            Give me strength to kick the smoking                 that's been causing all my choking.

     Let my breath be fresh and clean      without a trace of nicotine. Each ciggie I smoke so often

   Adds another nail in my coffin             Guide me Lord, by Your holy means                   past all those cigarette machines.

            It hurts to hear My Loved ones say                      kissing ya's like lickin' an ashtray.

      Please oh Lord, Hear my voice,                              give me will power, while I have a choice.

          I ask Your help and it's no wonder                                   because if I don't quit, I'm six feet under.

Health Is wealth

Thank you!