Uploaded byAlexandru Corlateanu
The assessment of management of stable COPD: an update 2014 by Corlateanu for COPD Istanbul 2014
The document discusses various approaches to assessing and managing stable COPD, including assessments of severity, phenotypes, and multilateral evaluation. It reviews markers used in different assessment approaches, such as FEV1, symptoms, health status, and exacerbation risk. Non-pharmacological treatments like smoking cessation, pulmonary rehabilitation, and vaccinations are outlined. The efficacy and safety of various pharmacological treatments is summarized based on major randomized controlled trials, including long-acting bronchodilators, inhaled corticosteroids, their combinations, and phosphodiesterase inhibitors. Therapeutic strategies for stable COPD are compared between GOLD guidelines and Spanish guidelines.
More Related Content
Similar to The assessment of management of stable COPD: an update 2014 by Corlateanu for COPD Istanbul 2014
The assessment of management of stable COPD: an update 2014 by Corlateanu for COPD Istanbul 2014
- 1. The assessment ofmanagement of stable COPD: An update Alexandru Corlateanu Department of Respiratory Medicine, State University of Medicine and Pharmacy "Nicolae Testemitanu", Chisinau, Moldova 1
- 2. Conflict of interest Receivedhonorariums for educational activities and lectures from GSK 2
- 3. 3 Nasreddin Hodja on Outcomesof COPD management
- 4. Nasreddin walked intoa house and exclaimed, "The moon is more useful than the sun." "Why?" "Because at night we need the light more" 4
- 5. CONTENTS • Actual COPDAssessments: Severity versus Clinical Phenotypes versus Multilateral assessment • Non-pharmacological treatment • Pharmacological treatment • Therapeutic Strategies in stable COPD 5
- 6.
- 7. Approaches to theassessment of COPD: • GOLD assessment of severity • multilateral evaluation • phenotyping 7
- 8. Markers used indifferent 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. Global Strategy forDiagnosis, 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. BMI Obstruction Dyspnea Exercise BODE Celli BR, CoteClaudia et al. NEJM 2004;350:1005-12 10
- 11. Ciro Casanova, ArmandoAguirre-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. Pink Puffer BlueBloater COPD Phenotypes Dornhorst AC, Lancet 1955 12
- 13. Spanish Guideline forCOPD (GesEPOC) 2014 Spanish Guideline for COPD (GesEPOC) / Arch Bronconeumol. 2014;50(Suppl 1):1-16 13
- 14. CONTENTS • Actual COPDAssessments: Severity versus Clinical Phenotypes versus Multilateral assessment • Non-pharmacological treatment • Pharmacological treatment • Therapeutic Strategies in stable COPD 14
- 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. Non-pharmacologic therapy •smoking cessation, •reductionof other risk factors, •vaccinations •pulmonary rehabilitation 16© 2014 Global Initiative for Chronic Obstructive Lung Disease
- 17. Smoking cessation shouldbe considered the most important intervention for all COPD patients who smoke regardless of the level of disease severity 17
- 18. Smoking and LungFunction 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. Nasreddin Hodja on drugsin COPD 19
- 20. Some children sawNasreddin 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.
- 22. TRIAL DURATION OUTCOMECOMPARATOR 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. Toward a Revolutionin COPD Health (TORCH) Calverley PM et al. N Engl J Med 2007;356:775-789.
- 24. RONALD DAHL; LOUISA. 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. Trial Duration OutcomeComparator 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. Once-daily indacaterol versustwice-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. Long-acting Bronchodilators Long-acting muscarinicantagonists 27
- 28. Trial Duration OutcomeComparator 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. Exacerbations of COPDand Related Hospitalizations Tashkin DP et al. N Engl J Med 2008;359:1543-1554.
- 30. Aclidinium Jones et al(ACCLAIM Iand 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. Efficacy and safetyof 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. Glycopyrronium D’Urzo et al (GLOW1) 26weeks ↑ 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. Efficacy and safetyof 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.
- 35. TRIAL ICS DURATIONOUTCOME 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 Soriano JB, SinDD, 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. Bronchodilators plus inhaledglucocorticoids 37
- 38. TRIAL ICS/LABA DURATIONOUTCOME 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. Efficacy and safetyof 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. Inhibitors of thePhosphodiesterase 4 inhibitors 40
- 41. Major randomized controlledtrials 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. Roflumilast Placebo 1.3 1.4 1.5 1.6 466 467 455 463 410 437 389 419 374 403 359 384 0 8 24412 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. CONTENTS • Actual COPDAssessments: Severity versus Clinical Phenotypes versus Multilateral assessment • Non-pharmacological treatment • Pharmacological treatment • Therapeutic Strategies in stable COPD 43
- 44. Comparison of GOLDand 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. Comparison of GOLDand 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. Comparison of GOLDand 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. Comparison of GOLDand 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. Comparison of GOLDand 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. • The managementof 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.