The assessment of management of
stable COPD: An update
Alexandru Corlateanu
Department of Respiratory Medicine, State Univ...
Conflict of interest
Received honorariums for educational
activities and lectures from GSK
2
3
Nasreddin Hodja on
Outcomes of COPD management
Nasreddin walked into a house and exclaimed,
"The moon is more useful than the sun."
"Why?"
"Because at night we need the ...
CONTENTS
• Actual COPD Assessments: Severity versus Clinical
Phenotypes versus Multilateral assessment
• Non-pharmacologic...
6
Approaches to the assessment of COPD:
• GOLD assessment of severity
• multilateral evaluation
• phenotyping
7
Markers used in different approaches
for COPD assessment
MARKERS GOLD 2011 MULTILATERAL INDICES
(BODE)
PHENOTYPING
SYMPTOM...
Global Strategy for Diagnosis, Management and Prevention of COPD
Combined Assessment of COPD
© 2014 Global Initiative for ...
BMI
Obstruction
Dyspnea
Exercise
BODE
Celli BR, Cote Claudia et al. NEJM 2004;350:1005-12 10
Ciro Casanova, Armando Aguirre-Jaíme, Juan P. de Torres, Victor Pinto-Plata, Rebeca Baz, Jose M. Marin,
Miguel Divo, Eliza...
Pink Puffer Blue Bloater
COPD Phenotypes
Dornhorst AC, Lancet 1955
12
Spanish Guideline for COPD (GesEPOC) 2014
Spanish Guideline for COPD (GesEPOC) / Arch Bronconeumol. 2014;50(Suppl 1):1-16
...
CONTENTS
• Actual COPD Assessments: Severity versus Clinical
Phenotypes versus Multilateral assessment
• Non-pharmacologic...
 Relieve symptoms
 Improve exercise tolerance
 Improve health status
 Prevent disease progression
 Prevent and treat ...
Non-pharmacologic therapy
•smoking cessation,
•reduction of other risk factors,
•vaccinations
•pulmonary rehabilitation
16...
Smoking cessation should be considered the most
important intervention for all COPD patients who smoke
regardless of the l...
Smoking and Lung Function of Lung Health Study Participants after 11 Years
Nicholas R. Anthonisen, John E. Connett, and Ro...
Nasreddin Hodja on
drugs in COPD
19
Some children saw Nasreddin coming from the vineyard with
two baskets full of grapes loaded on his donkey. They gathered
a...
Long-acting Bronchodilators
Long-acting β2-agonists
21
TRIAL DURATION OUTCOME COMPARATOR
SALMETEROL
Boyd et al 16 weeks ↑ FEV1 Placebo
Mahler et al 12 weeks ↑ FEV1 Placebo, ipra...
Toward a Revolution in COPD Health (TORCH)
Calverley PM et al. N Engl J Med 2007;356:775-789.
RONALD DAHL; LOUIS A. P. M. GREEFHORST; DARIUSZ NOWAK; VLADIMIR NONIKOV; AIDAN M. BYRNE; MOIRA H. THOMSON; DENISE
TILL; GI...
Trial Duration Outcome Comparator
Donohue et al
(INHANCE)
26 weeks ↑ HRQoL
↓ Dyspnoea (TDI)
Placebo, tiotropium
Dahl et al...
Once-daily indacaterol versus twice-daily salmeterol
for COPD: a placebo-controlled comparison
O. Kornmann, R. Dahl, S. Ce...
Long-acting Bronchodilators
Long-acting muscarinic antagonists
27
Trial Duration Outcome Comparator
Tiotropium
Brusasco et al 26 weeks ↓Exacerbations
↑ HRQoL
Placebo, salmeterol
Briggs et ...
Exacerbations of COPD and Related Hospitalizations
Tashkin DP et al. N Engl J Med 2008;359:1543-1554.
Aclidinium
Jones et al(ACCLAIM
I and II)
1 year ↑ Trough FEV1
↑ HRQoL
Placebo
Jones et al(ATTAIN) 6 months ↑ FEV1
↑ HRQoL
...
Efficacy and safety of twice-daily aclidinium bromide
in COPD patients: the ATTAIN study
Jones PW, Singh D, Bateman ED, et...
Glycopyrronium
D’Urzo et al
(GLOW1)
26 weeks ↑ FEV1
↑ HRQoL
↓Dyspnoea (TDI
score)
↓Exacerbations
Placebo
Kerwin et al
(GLO...
Efficacy and safety of once-daily NVA237 in patients with
moderate-to-severe COPD: the GLOW1 trial.
D’Urzo A, Ferguson GT,...
Inhaled Corticosteroids
34
TRIAL ICS DURATION OUTCOME COMPARATOR
Burge et al
(ISOLDE)
Fluticasone 1 year ↑ FEV1
↓ Exacerbations
Placebo
Calverley et ...
36
Soriano JB, Sin DD, Zhang X, et al. A pooled analysis of FEV1 decline in COPD patients randomized to
inhaled corticoste...
Bronchodilators plus inhaled glucocorticoids
37
TRIAL ICS/LABA DURATION OUTCOME COMPARATOR
Calverley et al Budesonide/formoterol 1 year ↓Exacerbations v P
and F
↔ FEV1 v ...
Efficacy and safety of budesonide/formoterol in the
management of COPD
39
▪: budesonide/formoterol;
▴: budesonide;
▾: form...
Inhibitors of the Phosphodiesterase 4 inhibitors
40
Major randomized controlled trials for
phophodiesterase inhibitors
TRIAL DRUG DURATION OUTCOME COMPARATOR
Rabe et al Roflu...
Roflumilast
Placebo
1.3
1.4
1.5
1.6
466
467
455
463
410
437
389
419
374
403
359
384
0 8 244 12 18
Weeks
Salmeterol + Place...
CONTENTS
• Actual COPD Assessments: Severity versus Clinical
Phenotypes versus Multilateral assessment
• Non-pharmacologic...
Comparison of GOLD and Spanish Guideline for
Treatment of stable COPD
GOLD
staging
GOLD 1st line Phenotypes Spanish Guidel...
Comparison of GOLD and Spanish Guideline for
Treatment of stable COPD
GOLD
staging
GOLD 1st line Phenotypes Spanish Guidel...
Comparison of GOLD and Spanish Guideline for
Treatment of stable COPD
GOLD
staging
GOLD 1st line Phenotypes Spanish Guidel...
Comparison of GOLD and Spanish Guideline for
Treatment of stable COPD
GOLD
staging
GOLD 1st line Phenotypes Spanish Guidel...
Comparison of GOLD and Spanish Guideline for
Treatment of stable COPD
GOLD
staging
GOLD 1st line Phenotypes Spanish Guidel...
• The management of COPD in every patient should be
personalized and guided by the symptoms, exacerbations,
pulmonary func...
50
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The assessment of management of stable COPD: an update 2014 by Corlateanu for COPD Istanbul 2014

  1. 1. The assessment of management of stable COPD: An update Alexandru Corlateanu Department of Respiratory Medicine, State University of Medicine and Pharmacy "Nicolae Testemitanu", Chisinau, Moldova 1
  2. 2. Conflict of interest Received honorariums for educational activities and lectures from GSK 2
  3. 3. 3 Nasreddin Hodja on Outcomes of COPD management
  4. 4. Nasreddin walked into a house and exclaimed, "The moon is more useful than the sun." "Why?" "Because at night we need the light more" 4
  5. 5. CONTENTS • Actual COPD Assessments: Severity versus Clinical Phenotypes versus Multilateral assessment • Non-pharmacological treatment • Pharmacological treatment • Therapeutic Strategies in stable COPD 5
  6. 6. 6
  7. 7. Approaches to the assessment of COPD: • GOLD assessment of severity • multilateral evaluation • phenotyping 7
  8. 8. Markers used in different approaches for COPD assessment MARKERS GOLD 2011 MULTILATERAL INDICES (BODE) PHENOTYPING SYMPTOMATIC dyspnea assessed by Medical Research Council scale dyspnea assessed by Medical Research Council scale symptoms PHYSIOLOGIC FEV1 FEV1 BMI, exercise capacity evaluated by 6 minute walking test FEV1 HEALTH STATUS the COPD Assessment Test (CAT) - - EXACERBATIONS evaluation of the risk of exacerbations - evaluation of the risk of exacerbations IMAGING - - X-Ray, HRCT Alexandru Corlateanu, Gloria Montanari, Alexandros G. Mathioudakis, Victor Botnaru and Nikolaos Siafakas. Management of Stable COPD: An Update. Current Respiratory Medicine Reviews 2014 inpress 8
  9. 9. Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD © 2014 Global Initiative for Chronic Obstructive Lung Disease Risk (GOLDClassificationofAirflowLimitation)) Risk (Exacerbationhistory) ≥ 2 or > 1 leading to hospital admission 1 (not leading to hospital admission) 0 Symptoms (C) (D) (A) (B) CAT < 10 4 3 2 1 CAT > 10 Breathlessness mMRC 0–1 mMRC > 2
  10. 10. BMI Obstruction Dyspnea Exercise BODE Celli BR, Cote Claudia et al. NEJM 2004;350:1005-12 10
  11. 11. Ciro Casanova, Armando Aguirre-Jaíme, Juan P. de Torres, Victor Pinto-Plata, Rebeca Baz, Jose M. Marin, Miguel Divo, Elizabeth Cordoba, Santiago Basaldua, Claudia Cote, Bartolomé R. Celli . Longitudinal assessment in COPD patients: multidimensional variability and outcomes Eur Respir J 2014 43:745-753 Longitudinal assessment in COPD patients: multidimensional variability and outcomes 11
  12. 12. Pink Puffer Blue Bloater COPD Phenotypes Dornhorst AC, Lancet 1955 12
  13. 13. Spanish Guideline for COPD (GesEPOC) 2014 Spanish Guideline for COPD (GesEPOC) / Arch Bronconeumol. 2014;50(Suppl 1):1-16 13
  14. 14. CONTENTS • Actual COPD Assessments: Severity versus Clinical Phenotypes versus Multilateral assessment • Non-pharmacological treatment • Pharmacological treatment • Therapeutic Strategies in stable COPD 14
  15. 15.  Relieve symptoms  Improve exercise tolerance  Improve health status  Prevent disease progression  Prevent and treat exacerbations  Reduce mortality Reduce symptoms Reduce risk Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Goals of Therapy © 2014 Global Initiative for Chronic Obstructive Lung Disease
  16. 16. Non-pharmacologic therapy •smoking cessation, •reduction of other risk factors, •vaccinations •pulmonary rehabilitation 16© 2014 Global Initiative for Chronic Obstructive Lung Disease
  17. 17. Smoking cessation should be considered the most important intervention for all COPD patients who smoke regardless of the level of disease severity 17
  18. 18. Smoking and Lung Function of Lung Health Study Participants after 11 Years Nicholas R. Anthonisen, John E. Connett, and Robert P. Murray American Journal of Respiratory and Critical Care Medicine 2002 166:5, 675-679 18 Smoking and Lung Function of Lung Health Study Participants after 11 Years
  19. 19. Nasreddin Hodja on drugs in COPD 19
  20. 20. Some children saw Nasreddin coming from the vineyard with two baskets full of grapes loaded on his donkey. They gathered around him and asked him to give them a taste. Nasreddin picked up a bunch of grapes and gave each child a grape. "You have so much, but you gave us so little," the children whined. 20 "There is no difference whether you have a basketful or a small piece. They all taste the same," Nasreddin answered, and continued on his way.
  21. 21. Long-acting Bronchodilators Long-acting β2-agonists 21
  22. 22. TRIAL DURATION OUTCOME COMPARATOR SALMETEROL Boyd et al 16 weeks ↑ FEV1 Placebo Mahler et al 12 weeks ↑ FEV1 Placebo, ipratropium* Rennard et al 12 weeks ↑ FEV1 Placebo Calverley et al (TRISTAN) 1 year ↑ FEV1 ↓Exacerbations ↑ HRQoL Placebo, fluticasone, fluticasone/salmeterol Calverley et al (TORCH) 3 years ↑ FEV1 ↓ Exacerbations ↑ HRQoL Placebo, fluticasone, salmeterol/fluticasone FORMOTEROL Dahl et al 12 weeks ↑ FEV1 ↓Symptom scores Placebo, ipratropium* De Rossi et al 1 year ↑ FEV1 Placebo, theophylline* Calverley et al 1 year ↔ FEV1 ↑ HRQoL Placebo, budesonide, budesonide/formoterol Szafranski et al 1 year ↔ FEV1 ↔HRQoL Placebo, budesonide, budesonide/formoterol Major randomized controlled trials of salmeterol and formoterol 22
  23. 23. Toward a Revolution in COPD Health (TORCH) Calverley PM et al. N Engl J Med 2007;356:775-789.
  24. 24. RONALD DAHL; LOUIS A. P. M. GREEFHORST; DARIUSZ NOWAK; VLADIMIR NONIKOV; AIDAN M. BYRNE; MOIRA H. THOMSON; DENISE TILL; GIOVANNI DELLA CIOPPA; Am J Respir Crit Care Med 2001, 164, 778-784. DOI: 10.1164/ajrccm.164.5.2007006
  25. 25. Trial Duration Outcome Comparator Donohue et al (INHANCE) 26 weeks ↑ HRQoL ↓ Dyspnoea (TDI) Placebo, tiotropium Dahl et al (INVOLVE) I year ↑ Bronchodilation (FEV1) ↑ HRQoL ↓ Dyspnoea (TDI) Prolonged time to exacerbation Placebo, formoterol Buhl et al (INTENSITY) 12 weeks ↔ Bronchodilation (FEV1) ↑ HRQoL ↓ Dyspnoea (TDI) Tiotropium Kornmann et al (INLIGHT-2) 12 weeks ↑ Bronchodilation (FEV1) ↑ HRQoL ↓ Dyspnoea (TDI) Placebo, salmeterol Korn et al (INSIST) 12 weeks ↑ Bronchodilation (FEV1) ↓ Dyspnoea (TDI) Salmeterol Major randomized controlled trials for indacaterol 25
  26. 26. Once-daily indacaterol versus twice-daily salmeterol for COPD: a placebo-controlled comparison O. Kornmann, R. Dahl, S. Centanni, on behalf of the INLIGHT-2 (Indacaterol Efficacy Evaluation Using 150-μg Doses with COPD Patients) study investigators .Once-daily indacaterol versus twice-daily salmeterol for COPD: a placebo-controlled comparison Eur Respir J 2011 37:273-279 26 ▴: salmeterol; ▪: indacaterol
  27. 27. Long-acting Bronchodilators Long-acting muscarinic antagonists 27
  28. 28. Trial Duration Outcome Comparator Tiotropium Brusasco et al 26 weeks ↓Exacerbations ↑ HRQoL Placebo, salmeterol Briggs et al 12 weeks ↑ FEV1 Salmeterol* Tashkin et al (UPLIFT) 4 years ↓Exacerbations ↑ HRQoL ↑ FEV1 Placebo Vogelmeier et al (POET) 1 year ↓Exacerbations Salmeterol* Major randomized controlled trials for tiotropium 28
  29. 29. Exacerbations of COPD and Related Hospitalizations Tashkin DP et al. N Engl J Med 2008;359:1543-1554.
  30. 30. Aclidinium Jones et al(ACCLAIM I and II) 1 year ↑ Trough FEV1 ↑ HRQoL Placebo Jones et al(ATTAIN) 6 months ↑ FEV1 ↑ HRQoL ↓ Dyspnoea (TDI) Placebo Kerwin et al (ACCORD) 12 weeks ↑ FEV1 ↑ HRQoL ↓ Dyspnoea (TDI) Placebo Fuhr et al 15 days per treatment Similar to ACCORD v placebo ↑ Morning FEV1 v tiotropium Placebo, tiotropium Major randomized controlled trials for aclidinium 30
  31. 31. Efficacy and safety of twice-daily aclidinium bromide in COPD patients: the ATTAIN study Jones PW, Singh D, Bateman ED, et al. Efficacy and safety of twice-daily aclidinium bromide in COPD patients: the ATTAIN study. Eur Respir J. 2012;40(4):830–6. 31
  32. 32. Glycopyrronium D’Urzo et al (GLOW1) 26 weeks ↑ FEV1 ↑ HRQoL ↓Dyspnoea (TDI score) ↓Exacerbations Placebo Kerwin et al (GLOW2) 1 year Similar to GLOW1 v placebo ↑ Bronchodilation on day 1 and week 26 v tiotropium Placebo, tiotropium* Beeh et al (GLOW3) 8 weeks ↑ Endurance time ↑ Inspiratory capacity Placebo Major randomized controlled trials for glycopyrronium 32
  33. 33. Efficacy and safety of once-daily NVA237 in patients with moderate-to-severe COPD: the GLOW1 trial. D’Urzo A, Ferguson GT, van Noord JA, et al. Efficacy and safety of once-daily NVA237 in patients with moderate-to-severe COPD: the GLOW1 trial. Respir Res. 2011;12:156. 33
  34. 34. Inhaled Corticosteroids 34
  35. 35. TRIAL ICS DURATION OUTCOME COMPARATOR Burge et al (ISOLDE) Fluticasone 1 year ↑ FEV1 ↓ Exacerbations Placebo Calverley et al Budesonide 1 year ↓ Exacerbations* ↑ HRQoL Placebo, formoterol, budesonide/formo terol Szafranski et al Budesonide 1 year ↑ FEV1 Placebo, formoterol, budesonide/formo terol Calverley et al (TRISTAN) Fluticasone 1 year ↑ FEV1 ↓Exacerbations Placebo, salmeterol, salmeterol/fluticas one Calverley et al (TORCH) Fluticasone 3 years ↓Exacerbations ↑ FEV1 Placebo, salmeterol, salmeterol/fluticas one Major randomized controlled trials for ICS 35
  36. 36. 36 Soriano JB, Sin DD, Zhang X, et al. A pooled analysis of FEV1 decline in COPD patients randomized to inhaled corticosteroids or placebo. Chest. 2007;131:682-689.
  37. 37. Bronchodilators plus inhaled glucocorticoids 37
  38. 38. TRIAL ICS/LABA DURATION OUTCOME COMPARATOR Calverley et al Budesonide/formoterol 1 year ↓Exacerbations v P and F ↔ FEV1 v all ↑ HRQoL v all Placebo, formoterol, budesonide Szafranski et al Budesonide/formoterol 1 year ↓Exacerbations v P and F ↔ FEV1 v P and B ↑ HRQoL v P and B Placebo, formoterol, budesonide Calverley et al (TRISTAN) Salmeterol/fluticasone 1 year ↑ FEV1 v all ↑ HRQoL v all ↓ Exacerbations v P Placebo, salmeterol, fluticasone Calverley et al (TORCH) Salmeterol/fluticasone 3 years ↓Exacerbations v all ↑ HRQoL v P Placebo, salmeterol, fluticasone Wedzicha et al (INSPIRE) Salmeterol/fluticasone 2 years ↔ Exacerbations ↑ HRQoL ↓ Mortality ↑ Pneumonia Tiotropium Major randomized controlled trials for ICS/LABA 38
  39. 39. Efficacy and safety of budesonide/formoterol in the management of COPD 39 ▪: budesonide/formoterol; ▴: budesonide; ▾: formoterol; ♦: placebo. W. Szafranski, A. Cukier, A. Ramirez, G. Menga, R. Sansores, S. Nahabedian, S. Peterson, H. Olsson . Efficacy and safety of budesonide/formoterol in the management of chronic obstructive pulmonary disease Eur Respir J 2003 21:74-81
  40. 40. Inhibitors of the Phosphodiesterase 4 inhibitors 40
  41. 41. Major randomized controlled trials for phophodiesterase inhibitors TRIAL DRUG DURATION OUTCOME COMPARATOR Rabe et al Roflumilast 24 weeks ↑ FEV1 ↓ Exacerbations Placebo Calverley et al Roflumilast 1 year ↑ FEV1 ↓Exacerbations* Placebo Calverley et al Roflumilast 1 year ↑ FEV1 ↓Exacerbations Placebo Fabbri et al Roflumilast 1 year ↑ FEV1 Placebo 41
  42. 42. Roflumilast Placebo 1.3 1.4 1.5 1.6 466 467 455 463 410 437 389 419 374 403 359 384 0 8 244 12 18 Weeks Salmeterol + Placebo Salmeterol+ Roflumilast Roflumilast as Add-On Therapy in COPD Pre-bronchodilator FEV1 Fabbri LM, Calverley PMA et al. Lancet 2009;374:695–703
  43. 43. CONTENTS • Actual COPD Assessments: Severity versus Clinical Phenotypes versus Multilateral assessment • Non-pharmacological treatment • Pharmacological treatment • Therapeutic Strategies in stable COPD 43
  44. 44. Comparison of GOLD and Spanish Guideline for Treatment of stable COPD GOLD staging GOLD 1st line Phenotypes Spanish Guidelines 1st line NON-EXACERBATOR (1 exacerbation not leading to hospital admission) A B SABA or SAMA LAMA or LABA non-exacerbator, with emphysema or chronic bronchitis LAMA or LABA SABA or SAMA EXACERBATOR (≥ 2 exacerbations or ≥ 1 exacerbation leading to hospital admission) C D ICS+LABA or LAMA ICS+LABA and/or LAMA exacerbator with emphysema exacerbator with chronic bronchitis LAMA or LABA LAMA or LABA Asthma COPD overlap syndrome (ACOS) No recommendations in GOLD 2014 mixed COPD-asthma phenotype LABA+ICS Alexandru Corlateanu, Gloria Montanari, Alexandros G. Mathioudakis, Victor Botnaru and Nikolaos Siafakas. Management of Stable Copd: An Update. Current Respiratory Medicine Reviews 2014 inpress 44
  45. 45. Comparison of GOLD and Spanish Guideline for Treatment of stable COPD GOLD staging GOLD 1st line Phenotypes Spanish Guidelines 1st line NON-EXACERBATOR (1 exacerbation not leading to hospital admission) A B SABA or SAMA LAMA or LABA non-exacerbator, with emphysema or chronic bronchitis LAMA or LABA SABA or SAMA EXACERBATOR (≥ 2 exacerbations or ≥ 1 exacerbation leading to hospital admission) C D ICS+LABA or LAMA ICS+LABA and/or LAMA exacerbator with emphysema exacerbator with chronic bronchitis LAMA or LABA LAMA or LABA Asthma COPD overlap syndrome (ACOS) No recommendations in GOLD 2014 mixed COPD-asthma phenotype LABA+ICS Alexandru Corlateanu, Gloria Montanari, Alexandros G. Mathioudakis, Victor Botnaru and Nikolaos Siafakas. Management of Stable Copd: An Update. Current Respiratory Medicine Reviews 2014 inpress 45
  46. 46. Comparison of GOLD and Spanish Guideline for Treatment of stable COPD GOLD staging GOLD 1st line Phenotypes Spanish Guidelines 1st line NON-EXACERBATOR (1 exacerbation not leading to hospital admission) A B SABA or SAMA LAMA or LABA non-exacerbator, with emphysema or chronic bronchitis LAMA or LABA SABA or SAMA EXACERBATOR (≥ 2 exacerbations or ≥ 1 exacerbation leading to hospital admission) C D ICS+LABA or LAMA ICS+LABA and/or LAMA exacerbator with emphysema exacerbator with chronic bronchitis LAMA or LABA LAMA or LABA Asthma COPD overlap syndrome (ACOS) No recommendations in GOLD 2014 mixed COPD-asthma phenotype LABA+ICS Alexandru Corlateanu, Gloria Montanari, Alexandros G. Mathioudakis, Victor Botnaru and Nikolaos Siafakas. Management of Stable Copd: An Update. Current Respiratory Medicine Reviews 2014 inpress 46
  47. 47. Comparison of GOLD and Spanish Guideline for Treatment of stable COPD GOLD staging GOLD 1st line Phenotypes Spanish Guidelines 1st line NON-EXACERBATOR (1 exacerbation not leading to hospital admission) A B SABA or SAMA LAMA or LABA non-exacerbator, with emphysema or chronic bronchitis LAMA or LABA SABA or SAMA EXACERBATOR (≥ 2 exacerbations or ≥ 1 exacerbation leading to hospital admission) C D ICS+LABA or LAMA ICS+LABA and/or LAMA exacerbator with emphysema exacerbator with chronic bronchitis LAMA or LABA LAMA or LABA Asthma COPD overlap syndrome (ACOS) No recommendations in GOLD 2014 mixed COPD-asthma phenotype LABA+ICS Alexandru Corlateanu, Gloria Montanari, Alexandros G. Mathioudakis, Victor Botnaru and Nikolaos Siafakas. Management of Stable Copd: An Update. Current Respiratory Medicine Reviews 2014 inpress 47
  48. 48. Comparison of GOLD and Spanish Guideline for Treatment of stable COPD GOLD staging GOLD 1st line Phenotypes Spanish Guidelines 1st line NON-EXACERBATOR (1 exacerbation not leading to hospital admission) A B SABA or SAMA LAMA or LABA non-exacerbator, with emphysema or chronic bronchitis LAMA or LABA SABA or SAMA EXACERBATOR (≥ 2 exacerbations or ≥ 1 exacerbation leading to hospital admission) C D ICS+LABA or LAMA ICS+LABA and/or LAMA exacerbator with emphysema exacerbator with chronic bronchitis LAMA or LABA LAMA or LABA Asthma COPD overlap syndrome (ACOS) No recommendations in GOLD 2014 mixed COPD-asthma phenotype LABA+ICS Alexandru Corlateanu, Gloria Montanari, Alexandros G. Mathioudakis, Victor Botnaru and Nikolaos Siafakas. Management of Stable Copd: An Update. Current Respiratory Medicine Reviews 2014 inpress 48
  49. 49. • The management of COPD in every patient should be personalized and guided by the symptoms, exacerbations, pulmonary function and co-morbidities. • Unfortunately very few treatments can slow the rate of decline in lung function or significantly reduce mortality, therefore prevention of the disease is very important. 49 Take home message
  50. 50. 50

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