This document summarizes the key changes to COPD treatment guidelines between GOLD 2001, 2011, and 2017. It discusses the evolution from a unidimensional to multidimensional approach. The 2017 guidelines classify patients into groups A-D based solely on symptoms and exacerbation history. Treatment is tailored to the group, starting with bronchodilators and escalating to dual/triple therapy as needed. The guidelines emphasize LAMA/LABA combination therapy and provide guidance on adding or withdrawing ICS.
Hello members...this is my 39th powerpoint...
It deals with LABA & SABA...The brochodilators used in the treatment of Pulmonary diseases like Asthma & COPD.
It gives a short insight into the drugs used, their indications with dosages, ADRs, interactions, etc.
Worthwhile for a precise information on the same!!
Happy reading!!!
:) :)
VIRAL PNEUMONIA BY DR BASHIR AHMED DAR ASSOCIATE PROFESSOR MEDICINE SOPORE KA...Prof Dr Bashir Ahmed Dar
DR BASHIR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIR PRESENTLY WORKING IN MALAYSIA TEACHING MEDICAL STUDENTS THE ART OF TREATING PATIENTS SPEAKS ABOUT THE IMPORTANCE OF HISTORY TAKING.MEDICAL STUDENTS AND DOCTORS should probe more deeply WHILE TAKING HISTORY OF A PATIENT as it gives the useful information in formulating a diagnosis and providing medical care to the patient.
Hello members...this is my 39th powerpoint...
It deals with LABA & SABA...The brochodilators used in the treatment of Pulmonary diseases like Asthma & COPD.
It gives a short insight into the drugs used, their indications with dosages, ADRs, interactions, etc.
Worthwhile for a precise information on the same!!
Happy reading!!!
:) :)
VIRAL PNEUMONIA BY DR BASHIR AHMED DAR ASSOCIATE PROFESSOR MEDICINE SOPORE KA...Prof Dr Bashir Ahmed Dar
DR BASHIR ASSOCIATE PROFESSOR MEDICINE SOPORE KASHMIR PRESENTLY WORKING IN MALAYSIA TEACHING MEDICAL STUDENTS THE ART OF TREATING PATIENTS SPEAKS ABOUT THE IMPORTANCE OF HISTORY TAKING.MEDICAL STUDENTS AND DOCTORS should probe more deeply WHILE TAKING HISTORY OF A PATIENT as it gives the useful information in formulating a diagnosis and providing medical care to the patient.
Chronic Stable Angina- Diagnosis & management
By Dr Awadhesh Kumar Sharma
Dr. Awadhesh kumar sharma is a young, diligent and dynamic interventional cardiologist. He did his graduation from GSVM Medical College Kanpur and MD in Internal Medicine from MLB Medical college jhansi. Then he did his superspecilisation degree DM in Cardiology from PGIMER & DR Ram Manoher Lohia Hospital Delhi. He had excellent academic record with Gold medal in MBBS,MD and first class in DM.He was also awarded chief ministers medal in 2009 for his academic excellence by former chief minister of UP Smt Mayawati in 2009.He is also receiver of GEMS international award.He had many national & international publications.He is also in editorial board of international journal- Journal of clinical medicine & research(JCMR).He is also active member of reviewer board of many journals.He is also trainee fellow of American college of cardiology. He is currently working in NABH Approved Gracian Superspeciality Hospital Mohali as Consultant Cardiologist.
COPD is a lung disease that makes it hard to breathe. It is caused by damage to the lungs over many years, usually from smoking.
The main symptoms are:
• A long-lasting (chronic) cough.
• Mucus that comes up when you cough.
• Shortness of breath that gets worse when you exercise.
We would like to intoduce you with BREATHE FREE!
Read more on it, See: http://www.nirogam.com/product_detail/333/Breathe-Free-60-Capsules-(Organic)
We are committed to your wellness and promise to help you with any health concern you may have. Please feel free to contact us via email or phone.
Nirogam India Pvt. Ltd.
F-32 & 33, 1st Floor
DLF Centre Point, Sector – 11,
Bata Mor, Main Mathura Road,
Faridabad, Haryana (India) - 121006
Mob: +91-9958171405 # 9015525552
Ph: 0129-4076777, 4006805
Email: support@nirogam.com
Facebook: www.facebook.com/nirogam
Web: www.nirogam.com
Chronic Stable Angina- Diagnosis & management
By Dr Awadhesh Kumar Sharma
Dr. Awadhesh kumar sharma is a young, diligent and dynamic interventional cardiologist. He did his graduation from GSVM Medical College Kanpur and MD in Internal Medicine from MLB Medical college jhansi. Then he did his superspecilisation degree DM in Cardiology from PGIMER & DR Ram Manoher Lohia Hospital Delhi. He had excellent academic record with Gold medal in MBBS,MD and first class in DM.He was also awarded chief ministers medal in 2009 for his academic excellence by former chief minister of UP Smt Mayawati in 2009.He is also receiver of GEMS international award.He had many national & international publications.He is also in editorial board of international journal- Journal of clinical medicine & research(JCMR).He is also active member of reviewer board of many journals.He is also trainee fellow of American college of cardiology. He is currently working in NABH Approved Gracian Superspeciality Hospital Mohali as Consultant Cardiologist.
COPD is a lung disease that makes it hard to breathe. It is caused by damage to the lungs over many years, usually from smoking.
The main symptoms are:
• A long-lasting (chronic) cough.
• Mucus that comes up when you cough.
• Shortness of breath that gets worse when you exercise.
We would like to intoduce you with BREATHE FREE!
Read more on it, See: http://www.nirogam.com/product_detail/333/Breathe-Free-60-Capsules-(Organic)
We are committed to your wellness and promise to help you with any health concern you may have. Please feel free to contact us via email or phone.
Nirogam India Pvt. Ltd.
F-32 & 33, 1st Floor
DLF Centre Point, Sector – 11,
Bata Mor, Main Mathura Road,
Faridabad, Haryana (India) - 121006
Mob: +91-9958171405 # 9015525552
Ph: 0129-4076777, 4006805
Email: support@nirogam.com
Facebook: www.facebook.com/nirogam
Web: www.nirogam.com
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanc...Michelle Peck
Michelle Peck | Geriatric Nurse Practitioner | Health Care Consultant | Professional Speaker | Nursing Faculty| Legal Nurse Consultant | Mindful Geriatrics
In collaboration with Dr. Linh Nguyen, Supportive Medicine at UTHealth Medical School, we have created this slide deck for Advanced Practice Nurses.
Our mission is to simplify the pharmacologic basics of good pain prescribing. We have not provided very much detail about schedule II controlled substances due to the current limitations on Texas Nurse Practitioner prescribing in primary care.
This lecture is designed to meet our Advanced Practice Nursing audience where they are at and provide tools, knowledge and practical tips. Areas where we detect mastery with our polling questions are briefly touched upon and more time and examples are given are to areas of audience identified needs. Prescribing pain medication for Advanced Practice Nurses is dynamic, complex and ever changing
We have also included a special focus (our passion) for pain prescribing in the geriatric population. Beer’s Criteria medications, to be used with caution or avoid completely in geriatrics are mentioned throughout this presentation.
This presentation starts with the audience writing down their biggest fear about pain prescribing. We then categorize these fears, so that throughout our lecture we can give special focus and alleviate fears with practical tips, guidelines and real life examples.
Our objectives are to discuss:
1. Benefits and side effects of common analgesics
2. The impact of patient-related factors on drug selection & dose based on knowledge of patient related changes
3. Medications to avoid, use with caution, explain why
4. Management of pain based on client care goals
We hope you Learn it-Live it-Love it!
BIOENGINEERED NANOROBOTICS FOR CANCER THERAPY Sivajith007
A person who is diagnosed with cancer will be offered a new alternative to chemotherapy because the traditional treatment of radiation that kills not just cancer cells but healthy human cells as well, causing hair loss, fatigue, nausea, depression, and a host of other symptoms. The application of nanorobotics can be considered as the better solution to this problems. Nanorobots are nanoelectromechanical systems designed to perform a specific task with precision at nanoscale dimensions. This technique involves the development of fully functional nanorobots capable of sensing, decision making, and actuation. From a bio inspired perspective, those in nanorobotics, including core design, propulsion and power generation, sensing, actuation, control, decision making, and system integration. The core of the nanorobots is a polysaccharide based nanoparticle, sensing and actuation ensure that it is capable of sensing and recognizing the cancer cell. These nanorobots may aid in cancer therapy, site-specific drug delivery, circulating diagnostics, advanced surgery, and tissue repair. One of the major advantages of nanorobots is it will not affect healthy cells in human body. Using strategies inspired from microorganisms, potential bioengineered nanorobots can be used for cancer therapy.
Geriatric Population. Pain and Palliative Care for the Older (Geriatric) AdultMichelle Peck
Michelle Peck | Legal Nurse | Nurse Practitioner | Health Care | Geriatric | Consultant | Speaker | Educator | Researcher
During your journey through this slide deck of Geriatric Populations, Pain and Palliative Care for the Older (Geriatric) Adult, you will experience: the assessment of pain; pain management strategies; and learn more about Palliative Care services.
As a health care consumer it is important to recognize and be aware of the quality of life benefits of good pain and symptom control. This begins with a good assessment of the factors contributing to the pain. Pain is a multifaceted experience. There are many barriers to achieving effective pain control in the elderly (geriatric population). Health care providers need to be aware of personal biases surrounding pain for proper pain management. There are also many health care provider misconceptions regarding Palliative Care especially in the geriatric population.
To enrich your geriatric understanding, at the end of this slide deck we discuss Palliative Care: the relief you need when you are experiencing serious medical illness.
Learn it-Live it-Love it-Your path for a more informed life!
Michelle Peck | Legal Nurse | Nurse Practitioner | Health Care | Geriatric | Consultant | Speaker | Educator | Researcher
A brief presentation on medicines optimisation and the input a clinical pharmacist can make in improving treatment outcomes for patients and help make evidence led cost effective improvements for the wider NHS.
Many questions arise around this topic: What is Artificial Intelligence and what isn't? What is possible today? How can my organisation use AI? Will this replace my job? What can we expect in the future?
We will answer these and more in our presentation. We help you understand the impact of digital on your business and give you concrete steps to start taking action.
ECO 11: Medicines Optimisation Through Precision - Sir Munir PirmohamedInnovation Agency
Munir Pirmohamed discusses the potential impact of medicines optimisation in terms of ensuring the right patients get the right choice if medicine at the right time. He presents a case history of over prescription and introduces three examples of medicines optimisation through use of genetics, big data, and pharmacogenetics profiling.
Charlie Keller, a primary care physician at Mercy Clinics, Inc. describes Mercy's experience with shared decision making implementation.
This presentation was part of a Shared Decision Making Month webinar -- Shared Decision Making in the Real World: Stories from the Frontline.
Translational Medicine: Patterns of Response to Antidepressant Treatment and ...Joanne Luciano
This is a talk I gave at the IEEE Schenectady Section - 17 MAY Membership Meeting.
The mission of my depression research is to help people figure out what they need to help them get out of a depressed state. That is, finding out what is best for them, not what is best for their doctor, friends, therapist, or anyone else. Depression is now a global problem. In the past 15 years it has gotten worse. Depression is complex; it has a wide range of varying symptoms and degrees of intensity. It can be challenging to determine the best course of action, whether medical treatment is necessary, or which of the many treatments (drug and non-drug) is the best match. Many people who are depressed do not get the help they need, and many people receive medications when they are not necessary. My work aims to bring together tools, technology, scientific and medical data and patient experience to help address depression, both personally and globally.
The latest guidelines on the management of a COPD patient ( Stable COPD, patient with an exacerbation of COPD), latest modalities of treatment of a COPD patient
The primary aims of COPD drug research are to develop agents capable of either inhibiting COPD-mediating inflammatory cell recruitment and activation directly, or indirectly - by targeting inflammatory mediators and blocking them from interacting with inflammatory cells.
As neutrophilic inflammation is present in most COPD cases, so first attempts at developing biologics for COPD therapy have focused on targeting the mechanisms of T1 inflammation.
Attempts at safe and effective mAb-mediated CXCR2 inhibition and TNF-a inhibition have also been unsuccessful, with high incidence of adverse effects and no improvements in patient health found in clinical trials.
Thus, further attempts at COPD biologics have turned their attention to primarily treating COPD related eosinophilia.
Chronic Obstructive Pulmonary Disease and Heart Failure The challenges facin...magdy elmasry
Chronic Obstructive Pulmonary Disease and Heart Failure
The challenges facing cardiologists and pulmonologists,
prevalence of heart failure in COPD patients .Association of Cardiovascular Disease With Respiratory Disease,An atypical presentation of myocardial infarction (MI) should be considered in every patient presenting with COPD exacerbation ,Cardiovascular and pulmonary disease in the context of inflammation
(“CardioPulmonary Continuum”),The cornerstones of therapy are beta-blockers and beta-agonists ,which as their modes of action suggest oppose each other’s action
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
29. 29
Expiratory flow-limitation and lung hyperinflation that are only partially reversible to
bronchodilator therapy are pathophysiological hallmarks of COPD
30. Children’s Healthcare of Atlanta
V
BD
Air flowDeflation
Improvement in flow – FEV1
Improvement in volumes – FVC and IC
Bronchodilator therapy deflates the lung
BD = bronchodilator; V = ventilation; FEV1= forced expiratory volume in 1 second;
FVC= forced vital capacity; IC = inspiratory capacity
42. 42
Less symptoms
High risk
Less symptoms
High risk
Less symptoms
Low risk
Less symptoms
Low risk
More symptoms
high risk
More symptoms
high risk
More symptoms
low risk
More symptoms
low risk
(GOLDClassificationofAirflowLimitation)
Risk
CAT < 10
Breathlessness
mMRC 0–1 mMRC ≥ 2
Symptoms CAT≥10
≥2
or
1 (not leading
to hospital
admission)
0
≥1 leading
to hospital
admission
GOLD 2011 Combined assessment of COPD
49. 49
Bronchodilators
Continue , stop or
try alternative
class of
bronchodilators
Evaluate effect
Group A Group B
A long – acting bronchodilators
( LABA or LAMA )
LAMA + LABA
Persistent
Symptoms
Group C
LAMA
LAMA + LABA LABA + ICS
Further
exacerbation(s)
Group D
LAMA LAMA + LABA LABA + ICS
LAMA
+ LABA
+ ICS
Consider Roflumilast
if FEV1 50% pred.˂
And patient has
chronic bronchitis
Consider
macrolides in
former smokers
Further exacerbation(s)
Further
exacerbation(s)
Persistent
Symptoms / further
exacerbation(s)
51. 51
• "This is a major revision of the GOLD document since
2011 and is a step forward for individualised COPD
management.
• The updated pharmacotherapy recommendations are
now based solely on two factors, symptoms and
exacerbation history,"
GOLD2017GOLD2017
52. 52
Revised combined COPD assessment
• A refinement of the ABCD assessment tools is proposed that
separates spirometric grades from the “ ABCD “ groups
• ABCD groups will be derived exclusively from patient
symptoms & exacerbations history
• Spirometery in conjugation with patient symptoms &
exacerbation history remains vital for :
1) Diagnosis
2) Prognostication
3) Therapeutic approaches
56. 56
All Group A patients should be offered bronchodilators
treatment based on it’s effect on breathlessness ( this
can be either short- or long-acting bronchodilator ) .
This should be continued if symptomatic benefits is
documented.
if necessary, an alternative class of bronchodilator
(alternative mono bronchodilator )can be used if benefit
is not achieved with the first.
58. 58
Group B
A long – acting bronchodilators
( LABA or LAMA )
LAMA + LABA
Persistent
Symptoms
59. 59
For Group B patients, therapy should begin with a long-
acting bronchodilator LABA or LAMA , (no evidence to
recommend one over another), and should be escalated to
two bronchodilators if breathlessness continues with
monotherapy.
If breathlessness is severe, starting the patient on dual
long-acting bronchodilators can be considered, however if
the second therapy does not improve symptoms, the
guidelines suggest stepping down to one bronchodilator.
73. 73
For Group C patients, it is recommended that treatment be
started with a single long-acting bronchodilator,
preferably a LAMA (LAMA was superior to the LABA
regarding exacerbation prevention).
A second long-acting bronchodilator or the combination of
LABA/ICS may be used for persistent exacerbations;
The guidelines recommend LABA/LAMA as the addition of
ICS has been shown to increase pneumonia risk in some
patients.
74. 74
Inhaled Steroids in COPD
Exacerbation reduction when
added to LABD in placebo-
controlled trials
Improvement in FEV1 in
combination with beta-
agonists
Clinical trial evidence
o No reduction in COPD
progression
o No mortality reduction
Side effect profile
o Risk of pneumonia
o Risk of osteoporosis, adrenal
suppression
o Hoarse voice
o Oral Thrush
ConsPros
Burge PS, et al. BMJ. 2000;320(7245):1297-1303.
Calverley PM, et al. NEJM. 2007;356:775-789.
Festic E, et al. AJRCCM. 2015;191:141-148.
Kaplan AG. Int J COPD. 2015;10:2535-2548.
Suissa S, et al. Eur Resp J. 2015;46:1232-1235.
75. 75
Risk of patients with COPD developing serious pneumonia is
particularly elevated and dose-dependent with fluticasone
propionate use, and comparatively much lower with
budesonide.
Based on the latest EMA review on ICS for COPD overall the
benefits of inhaled corticosteroid medicines in treating COPD
continue to outweigh their risks
80. 80
Group D
LAMA LAMA + LABA LABA + ICS
LAMA
+ LABA
+ ICS
Consider Roflumilast
if FEV1 50% pred.˂
And patient has
chronic bronchitis
Consider macrolides in
former smokers
Further exacerbation(s)
Further exacerbation(s)
Persistent
Symptoms / further
exacerbation(s)
81. 81
For Group D patients, a LABA/LAMA combination is
preferred as initial therapy over LABA/ICS as these patients
may be at higher risk of developing pneumonia with ICS
use.
For patients with high blood eosinophil counts or those
with asthma-COPD overlap, LABA/ICS could be considered
first-line therapy.
82. 82
The GOLD Report also reinforces the role of ICS/LABA for
patients that have asthma features and/or high blood
eosinophil count, and patients who show more frequent
exacerbations.
For the first time the GOLD Report recognises eosinophils as
a potential decision-driver for COPD treatment and
as a biomarker for risk of exacerbations and identifying ICS
responders
83. 83
In patients who develop further exacerbations on
LABA/LAMA therapy we suggest two alternative
pathways:
1.Escalation to LABA/LAMA/ICS (Triple therapy).
2.Switch to LABA/ ICS
If LABA/ICS therapy does not positively impact
exacerbations/symptoms a LAMA can be added.
85. 85
• For patients who still have exacerbations with
LABA/LAMA/ICS, the following three options can be
considered:
• 1) adding roflumilast (for patients with FEV1<50% predicted
and chronic bronchitis)
• 2) adding a macrolide (azithromycin preferred, however,
antibiotic resistance should be factored in decision-
making)
• 3) discontinuing ICS.
91. 91
The Role of Inhaled Steroids in COPD
Pharmacotherapy
There is no advantage in adding ICS to bronchodilator
therapy in patients at low risk of exacerbations .
Early observational studies suggested that simply stopping
therapy increased the risk of exacerbations. However more
recent data suggest that this may not be true if the patient is
receiving long-acting inhaled bronchodilators .
95. 95
6-7 0
S
C
R
E
E
N
I
N
G
Treatment
52Week -6
ICS
(remained on triple therapy from run-in)
Stepwise ICS withdrawal
(remained on dual bronchodilator)
Run-in
Triple
therapy
12
R
A
N
D
O
M
I
S
A
T
I
O
N
ICS stepwise withdrawal Stable
treatment
Reduced to 250 µg BID
Reduced to 100 µg BID
Reduced to 0 µg (placebo)
Fluticasone propionate 12-week
withdrawal schedule
500 µg BID
18
• Tiotropium 18 µg QD
• Salmeterol 50 µg BID
• Fluticasone propionate 500 µg BID
Triple therapy
regimen
WISDOM: Study design
100. 100
Triple therapy may be over used in COPD patients today so ,
Constant evaluation of COPD patients and changes in
patient status over time is essential to good patient care
Step down therapy, by stopping ICS use in patients on
triple therapy , may be considered under the right set of
conditions in selected patients
Patients undergoing treatment step down require close
monitoring to insure no adverse effects over time,
especially COPD exacerbations, are associated with the
change in therapy.
102. 102
Bronchodilators
Continue , stop or
try alternative
class of
bronchodilators
Evaluate effect
Group A
Group B
A long – acting bronchodilators
( LABA or LAMA )
LAMA + LABA
Persistent
Symptoms
Group C
LAMA
LAMA + LABA LABA + ICS
Further
exacerbation(s)
Group D
LAMA LAMA + LABA LABA + ICS
LAMA
+ LABA
+ ICS
Consider Roflumilast
if FEV1 50% pred.˂
And patient has
chronic bronchitis
Consider
macrolides in
former smokers
Further exacerbation(s)
Further
exacerbation(s)
Persistent
Symptoms / further
exacerbation(s)
104. 104
Treatment recommendations are tailored to patient needs
based only on symptoms and exacerbation history.
For patients with only occasional symptoms, a short acting
bronchodilator, either a short-acting beta-agonist (SABA)
or a short-acting muscarinic antagonist (SAMA) is
recommended.
105. 105
For patients with persistent symptoms, either a (LABA) or a
(LAMA) is recommended.
For patients with persistent symptoms on single bronchodilator
therapy, advancement to dual therapy with a LAMA plus a
LABA, or combination ICS/LABA is recommended, with a
preference given to dual-bronchodilator therapy.
106. 106
ICS are not recommended as monotherapy in COPD .
ICS-containing pharmaceutical regimens no longer
recommended as first-choice treatments for COPD of any
severity .
Combination agents containing ICS + LABA are considered
appropriate step-up therapy for patients experiencing COPD
exacerbations while taking long-acting bronchodilators.
107. 107
The new GOLD Strategy provides clear guidance on when
and in which patients ICS can be added or withdrawn.
Only those who have ≥2 exacerbations/year or ≥1 leading to
hospital admission may be considered for an ICS containing
therapy after LAMA/LABA.
In addition, the new GOLD Strategy suggests that ICS therapy
may be withdrawn safely (de-escalation path ) in people with
COPD who are in GOLD group D and stable, by using a
LAMA/LABA regimen.
108. 108
The updated 2017 GOLD Strategy now positions a combination
of a LAMA (long-acting muscarinic receptor antagonists ) and
a LABA (long-acting beta2-agonist), as a mainstay treatment
for people with COPD in GOLD groups B-D.
This represents a significant change versus previous GOLD
guidelines.
109. 109
The GOLD Report acknowledges the potential benefits of
escalation to triple therapy for those patients who are still
exacerbating despite a LAMA/LABA or still symptomatic on
ICS/LABA .
The GOLD Report now mentions roflumilast ( PDE-4
inhibitor ) as an additional treatment option on top of
triple therapy in patients with FEV1 <50% predicted and
chronic bronchitis who still have exacerbations .
110. 110
Inhaled bronchodilators preferred over oral bronchodilators
(A)
Theophylline not recommended; only to be used if other long-
term treatments are not available or unaffordable (B)
112. 112
LAMA/LABA therapy now an essential cornerstone for
COPD treatment across the spectrum of people with COPD
in GOLD groups B-D
Clearer guidance for physicians on which subset of
patients may benefit from the addition of ICS
The Winner of GOLD 2017
113. 113
GOLD 2017 represents a big win for makers of the next-
generation LAMA+LABA combination inhaler treatments.
Once-daily combination inhalers for COPD will likely result
in better adherence, which could result in improved health
outcomes compared to those regimens requiring multiple
devices .
114. 114
The newest COPD combination inhalers aren't on all
formularies and will be out of financial reach for many
patients .
The 2017 GOLD guidelines emphasizing:
The choice of inhaler device has to be individually tailored
and will depend on access, cost, prescriber, and most
importantly the patient's ability and preference .
In other words, the best inhaler for COPD is the one a
patient can afford, understands, agrees with and will use
regularly.