Download Helping patients with COPD breathe easier

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Helping patients with COPD
breathe easier
COPD is the third-leading cause of death in
the U.S., following cancer and heart disease1
Women have overtaken men in annual COPD deaths.
FIGURE 1. COPD deaths by gender 2.3
135,000
total deaths
80,000
122,000
total deaths
Number of deaths
70,000
60,000
54,000
total deaths
50,000
147,101
total deaths
Women
Men
83,000
total deaths
40,000
30,000
20,000
10,000
0
1979
1989
1999
2009
2014
Year
Patients with COPD cost $6000 more per year than other patients.4
Primary care providers play a central role in managing these patients.
• COPD is substantially under-diagnosed.
• It can occur at an earlier age than is generally believed.
• Early diagnosis and aggressive treatment can:
——reduce
——slow
mortality
disease progression and relieve symptoms
——improve
——reduce
2
pulmonary function and quality of life
exacerbations
Helping patients with COPD breathe easier
Using symptoms plus spirometry improves
the diagnosis and staging of COPD
• Suspect COPD in patients over age 40 with dyspnea, chronic cough or sputum
production, and a history of smoking or exposure to other risk factors.
• FEV1 /FVC ratio <0.70 (post-bronchodilator) confirms COPD.
TABLE 1. The GOLD Classification Scheme can guide treatment5
Postbronchodilator
FEV1
Exacerbations
Symptoms*
>50% of predicted
<50% of predicted
AND
AND/OR
<2 per year
≥ 2 per year
LOW RISK
HIGH RISK
Moderate
Severe
Moderate
Severe
GROUP A
GROUP B
GROUP C
GROUP D
[low risk of
[low risk of
[high risk of
[high risk of
exacerbation,
exacerbation,
exacerbation,
exacerbation,
fewer symptoms] more symptoms] fewer symptoms] more symptoms]
*Severe symptoms: walking slower than people of the same age because of breathlessness or
needing to stop for breath on level ground (MMRC scale6).
Other clinical factors may influence treatment decisions:
• Functional impairment (e.g., exercise tolerance, ability to perform activities
of daily living)
• Co-morbidities (e.g., co-existing asthma)
Repeat spirometry if symptoms worsen significantly.
Routine spirometry in stable disease is unnecessary.
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Smoking cessation is the most effective
single action to delay COPD symptoms,
onset of disability, and mortality 7
FIGURE 2. Smoking and decline of lung function in COPD 8
Lung function
FEV1 (% of value at age 25)
100
Susceptible
smoker
75
Never smoked
or not susceptible
to smoke
50
Stopped smoking
at age 45
Disability
25
Stopped smoking
at age 65
Death
0
25
50
Years
75
Even brief, simple advice about quitting smoking increases the likelihood that a smoker
will successfully quit and remain a nonsmoker 12 months later. More intensive advice
may result in higher rates of quitting.9
Encourage patients to call 1-800-QUIT-NOW (1-800-784-8669) for help or text
QUIT to 47848 to receive text messages. Visit AlosaHealth.org/modules/COPD
for more resources and information about smoking cessation.
4
Helping patients with COPD breathe easier
First, assess willingness to quit:
Tailoring recommendations to the stage of readiness can increase success.
The five As of assessing readiness to quit smoking:
Ask:
Identify tobacco use at every visit; electronic prompts for clinicians can be helpful.
Advise:
Strongly urge all tobacco users to quit, using a clear and personalized message.
Assess:
Determine willingness to make a quit attempt.
Assist:
Help with a quit plan; recommend support programs and medications if required.
Arrange: Schedule follow-up contact, in person or by telephone.
Multiple drug therapy options are available to support patients
who are ready to quit.
• Over-the-counter:
——nicotine replacement therapy
(gum, lozenges, transdermal patches,
inhaled and nasal spray)
• Prescription medications:
——bupropion (Zyban, Wellbutrin, generics)
——varenicline
(Chantix)
• Nicotine replacement products may be combined with either bupropion or varenicline.
• Many options are available if multiple quit attempts are required.
• For patients with COPD, there is no comparison to show that one drug is better
than another.10
Treatment options may be selected based on patient preference, cost,
and relevant medical and/or psychiatric conditions.
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Match drug therapy to disease severity
TABLE 2. Pharmacological management of COPD 5
Group A
Group B
Group C
Group D
First line therapy
Short-acting
ß-agonist PRN
(SABA)
Long-acting
ß-agonist (LABA)
Inhaled corticosteroid
(ICS)+ long-acting
ß-agonist (LABA)
Inhaled corticosteroid
(ICS)+ long-acting
ß-agonist (LABA)
—OR—
—OR—
—OR—
—AND/OR—
Short-acting
anticholinergic PRN,
or “short-acting
muscarinic
antagonist” (SAMA)
Long-acting
anticholinergic,
or “long-acting
muscarinic
antagonist” (LAMA)
Long-acting
anticholinergic,
or “long-acting
muscarinic
antagonist” (LAMA)
Long-acting
anticholinergic,
or “long-acting
muscarinic
antagonist” (LAMA)
Add short-acting bronchodilators as rescue medication as needed
Optional alternative therapies:
Group A: [SABA + SAMA] or [LABA] or [LAMA]
Group B: [LABA + LAMA]
Group C: [LABA + LAMA] or [LAMA + roflumilast] or [LABA + roflumilast]
Group D: [ICS + LABA + LAMA] or [ICS + LABA + roflumilast] or [LABA + LAMA] or [LAMA + roflumilast]
Short- and long-acting bronchodilators
Short-acting
SABA
• albuterol
(Proventil HFA)
• levalbuterol
(Xopenex HFA)
Long-acting
SAMA
• ipratropium
(Atrovent and
generics)
LABA
• salmeterol
(Serevent)
• formoterol (Foradil)
• aformoterol (Brovana)
• indacaterol (Arcepta)
LAMA
• tiotropium (Spiriva)
• aclidinium
(Tudorza)
• umeclidinium
(Incruse)
• olodaterol (Striverdi)
Ensure the patient can demonstrate proper use of inhalers and spacers.
See AlosaHealth.org/modules/COPD for links to videos for patient education.
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Helping patients with COPD breathe easier
Step up treatment as symptoms escalate
Start with a single SABA or SAMA.
A combination of short-acting therapy may result in improved lung function and is
an alternative choice, though the COMBIVENT study found that combination therapy
with albuterol and ipratropium did not improve symptoms more than monotherapy.11
For increasing symptoms, LABAs and LAMAs reduce exacerbations
and provide more relief than short-acting agents.
The POET-COPD trial found that tiotropium was more effective than salmeterol
in reducing the risk of moderate to severe exacerbations.12
For more severe patients, combination therapy may be warranted.
While LABA + ICS and LAMA are both effective,13 the FLAME study found that
combined bronchodilation with LAMA + LABA delayed time to exacerbation and
reduced exacerbations overall compared with a LABA + ICS. Symptoms improved
and use of rescue inhaler was lower in the LAMA + LABA group as well.14
Some patients may require triple therapy (LABA + LAMA + ICS).15
Reserve phosphodiesterase-4 (PDE-4) inhibitors (e.g., roflumilast) for patients with an
FEV1 <50% who have frequent exacerbations despite optimal conventional therapy.16
Prescribe home oxygen in severe disease if:
• O2 saturation ≤88% or PaO2 ≤55 mm Hg, or
• PaO2 of 55-59 mm Hg with evidence of pulmonary hypertension,
cor pulmonale, hematocrit >55%, or
• PaO2 ≥60 mm Hg with exercise desaturation, sleep desaturation
not corrected by continuous positive airway pressure (CPAP),
or severe dyspnea that responds to oxygen therapy.17
At least 15 hours/day of oxygen or more improves survival.18,19
Note: When titrating oxygen, aim for an O2 saturation >90%.
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Prescribe exercise, good nutrition, and
immunizations at all stages of the disease
TABLE 3. Non-pharmacological interventions for COPD 5
Group A
Group B
Group C
Group D
Smoking cessation
Reduce occupational and environmental exposures
Exercise/physical therapy
Good nutrition
Influenza and pneumococcal vaccines
Pulmonary rehabilitation
Pulmonologist referral
Address end-of-life decision making
Consider surgery
in selected patients
Exercise and pulmonary rehabilitation
Pulmonary rehabilitation reduces hospital admissions and mortality. It also increases exercise
capacity, reduces breathlessness symptoms, improves quality of life, relieves anxiety and
depression, and reduces days spent in hospital.5
Relative risk reduction
compared to usual care (%)
FIGURE 3. Pulmonary rehab reduces hospital admissions and mortality after an exacerbation20
0
• Standard duration is 6 weeks; then continue
exercise at home.
-10
-20
• If a formal program is unavailable, encourage a
walking regimen, building slowly to 20 minutes/day.
-30
-40
-50
-60
-70
-52%
-60%
Hospital
admissions
Mortality
——An inexpensive finger pulse oximeter may enable
patients to safely build exercise tolerance and
avoid excessive desaturation.
Immunization
• Annual influenza vaccination reduces mortality 21 and risk of exacerbations.22
• Provide pneumococcal vaccination for all patients with COPD.23
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Helping patients with COPD breathe easier
Exacerbations reduce long-term lung
function and increase mortality
Exacerbations are characterized by worsening symptoms (e.g., worsening
dyspnea, increased volume or purulence of sputum, cough).
Prevent exacerbations by:
3promoting smoking cessation
3monitoring proper inhaler use
3ensuring adherence to prescribed regimens
3providing influenza immunizations
FIGURE 4. Most exacerbations can be managed in the outpatient setting.5
• Increase bronchodilator therapy.
—SABA with or without SAMA are preferred.
• Add oral prednisone.
—The REDUCE trial found that prednisone 40 mg/day for 5 days achieved
equivalent outcomes to a 14-day regimen.24
• Add antibiotics in patients with increased sputum purulence plus worsening
dyspnea or increased sputum volume.
—Base the choice of antibiotic on local resistance patterns.
—Examples include amoxicillin +/- clavulanic acid (e.g. Augmentin).
—If penicillin allergy, use a macrolide, doxycycline, or tetracycline.
Improvement or resolution of symptoms within 24 hours?
!
Y
N
Step down therapy as possible.
Review management plan.
Hospitalize
Oral corticosteroids—for acute exacerbations only
Avoid long-term use of oral steroids in COPD because of the risk of
osteoporosis, hypertension, hyperglycemia, and other adverse effects.
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Costs
FIGURE 5. Price per month of medications used for the treatment of COPD and smoking cessation
SABA
$23
albuterol (Ventolin HFA)
$84
albuterol (Proair HFA, Proventil HFA)
$17
albuterol (generic) for nebulization
$85
levalbuterol (Xopenex HFA)
SAMA
$24
iptratropium (generic) for nebulization
$398
ipratropium (Atrovent HFA)
LABA
$250
formoterol (Foradil)
$989
aformoterol (Brovana)
$227
indacaterol (Arcapta)
$425
salmeterol (Serevent Discus)
LAMA
aclidinium (Tudorza Pressair)
$387
tiotropium (Spiriva)
$389
$330
umeclidinium (Incruse Ellipta)
SABA / SAMA
$354
albuterol/ipratropium (Combivent)
LABA / LAMA
indacaterol 27.5 mcg/glycopyrrolate 15.6 mcg (Utibron Neohaler)
$321
$376
valanterol 25 mcg/umeclidinium 62.5 mcg (Anoro Ellipta)
$322
formoterol 4.8 mcg/glycopyrrolate 9 mcg (Bevespi Aerosphere)
$361
olodaterol 2.5 mcg/tiotropium 2.5 mcg (Stiolto Respimat)
ICS
$274
budesonide 180 mcg (Pulmicort)
$245
beclomethasone 80 mcg (QVAR)
$262
fluticasone 250 mcg (Flovent Discus)
LABA/ICS
$334
budesonide 160 mcg/formoterol 4.5 mcg (Symbicort)
$382
fluticasone 250 mcg/salmeterol 50 mcg (Advair Discus)
$341
fluticasone 100 mcg/vilanterol 25 mcg (Breo Ellipta)
PDE-4 inhibitor
Smoking cessation
$351
roflumilast (Daliresp) 0.5 mg tablet
$412
varenicline 2 mg (Chantix)
$73
bupropion SR 300 mg (generic)
$448
bupropion SR 300 mg (Wellbutrin SR)
$243
bupropion SR 300 mg (Zyban)
$433
nicotine inhaler (Nicotrol)
nicotine gum 4 mg (Nicorette)
$53
nitotine patch 14 mg (Nicoderm CQ)
$53
0
* Prices from goodrx.com September 2016.
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Helping patients with COPD breathe easier
$200
$400
$600
$800
$1000
Key messages
• Use spirometry and clinical symptoms to diagnose and follow COPD patients
according to the GOLD 4-group classification system.
• For patients who smoke, begin by assessing their willingness to quit. Tailoring
recommendations appropriate for their stage of readiness will increase success.
• Prescribe a regimen of exercise, good nutrition, and immunizations at all stages
of COPD.
——Refer
to formal pulmonary rehab (as a form of exercise) if available.
• Match drug therapy to disease severity according to the GOLD 4-group system.
——Begin
with prn inhaled bronchodilators (SABA and/or SAMA).
——Sequentially
add long-acting agents including inhaled corticosteroids.
——PDE-4
inhibitors may be an alternative long-acting agent for some
with severe disease.
• Prescribe oxygen for patients with chronic hypoxemia.
• Treat acute exacerbations aggressively with short-acting bronchodilators,
systemic steroids, and an antibiotic when appropriate.
Visit AlosaHealth.org/modules/COPD
for patient resources and more detailed information
References:
(1) American Lung Association. Trends in COPD (Chronic Bronchitis and Emphysema): Morbidity and Mortality. 2013. (2) Centers for Disease Control and Prevention.
National Center for Health Statistics, CDC Wonder on-line database, compiled from compressed mortality file. 1979-2009. 2012;No. 20. (3) Centers for Disease Control
and Prevention. National Center for Health Statistics. National Vital Statistics Reports 2010 to 2014. http://www.cdc.gov/nchs/products/nvsr.htm (4) Ford ES, Murphy
LB, Khavjoy O, et al. Total and state-specific medical and absenteeism costs of COPD among adults aged ≥ 18 years in the United States for 2010 and projections
through 2020. Chest. 2015;147:31-45. (5) GOLD. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2016.
(6) Stenton C. The MRC breathlessness scale. Occup Med. 2008;58(3):226-227. (7) Godtfredsen NS, Lam TH, Hansel TT, et al. COPD-related morbidity and mortality
after smoking cessation: status of the evidence. Eur Respir J. 2008;32(4):844-853. (8) Fletcher C, Peto R. The natural history of chronic airflow obstruction. BMJ.
1977;(1(6077)):1645-1648. (9) Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2008(2):CD000165.
(10) van Eerd EAM, van der Meer RM, vanSchayck OCP, Kotz D. Smoking cessation for people with chronic obstructive pulmonary disease. Cochrane Database
Syst Rev. 2016: CD010744. (11) Routine nebulized ipratropium and albuterol together are better than either alone in COPD. The COMBIVENT Inhalation Solution
Study Group. Chest. 1997;112(6):1514-1521. (12) Vogelmeier C, Hederer B, Glaab T, et al. Tiotropium versus salmeterol for the prevention of exacerbations of COPD.
NEJM. 2011;364(12):1093-1103. (13) Wedzicha JA, Calverley PM, Seemungal TA, Hagan G, Ansari Z, Stockley RA. The prevention of chronic obstructive pulmonary
disease exacerbations by salmeterol/fluticasone propionate or tiotropium bromide. Am J Respir Crit Care Med. 2008;177(1): 19-26. (14) Wedzicha JA, Banerji D,
Chapman KR, et al. Indacaterol-glycopyrronium versus salmeterol-fluticasone for COPD. N Engl J Med. 2016;374:2222-34. (15) Singh D, Papi A, Corradi M, et al.
Single inhaler triple therapy versus inhaled corticosteroid plus long-acting ß2-agonist therapy for chronic obstructive pulmonary disease (TRILOGY): a double-blind,
parallel group, randomized controlled trial. Lancet. 2016;388:963-73. (16) Chong J, Poole P, Leung B, Black PN. Phosphodiesterase 4 inhibitors for chronic obstructive
pulmonary disease. Cochrane Database Syst Rev. 2011(5):CD002309. (17) American Thoracic Society ERS. Standards for the Diagnosis and Manangement of
Patients with COPD. 2004. (18) Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypozemic chronic obstructive lung disease:
a clinical trial. Ann Intern Med. 1980;93(3):391-398. (19) Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis
and emphysema. Report of the Medical Research Council Working Party. Lancet. 1981;1(8222):681-686. (20) Puhan M, Gimeno-Santos E, Scharplatz M, Troosters T,
Walters EH, Steurer J. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2011(10):CD005305.
(21) Schembri S, Morant S, Winter JH, MacDonald TM. Influenza but not pneumococcal vaccination protects against all-cause mortality in patients with COPD. Thorax.
2009;64(7):567-572. (22) Poole PJ, Chacko E, Wood-Baker RW, Cates CJ. Influenza vaccine for patients with chronic obstructive pulmonary disease. Cochrane Database
Syst Rev. 2006(1):CD002733. (23) Nichol KL, Baken L, Wuorenma J, Nelson A. The health and economic benefits associated with pneumococcal vaccination of
elderly persons with chronic lung disease. Arch Intern Med. 1999;159(20):2437-2442. (24) Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional
glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA. 2013;309(21):2223-2231.
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About this publication
These are general recommendations only; specific clinical decisions should be made by the
treating physician based on an individual patient’s clinical condition. More detailed information
on this topic is provided in a longer evidence document at AlosaHealth.org.
This material is provided by Alosa Health, a nonprofit organization
which is not affiliated with any pharmaceutical company.
This material was produced by Michael H. Cho, M.D., MPH, Assistant Professor of Medicine; Michael
A. Fischer, M.D., M.S., Associate Professor of Medicine; Niteesh K. Choudhry, M.D., Ph.D., Professor of
Medicine; Jerry Avorn, M.D., Professor of Medicine, all at Harvard Medical School; and Ellen Dancel,
PharmD, MPH, Director of Clinical Material Development at Alosa Health. Drs. Avorn, Cho, Choudhry,
and Fischer are all physicians at the Brigham and Women’s Hospital in Boston and do not accept any
personal compensation from any drug company.
Medical writer: Stephen Braun.
Copyright 2016 by Alosa Health. All rights reserved.