2. ASTHMA - COPD
Dr. Nino JN Doydora
Section of Pulmonary Medicine
3. Disclosures
Novartis
A 52-week Treatment, Multi-Center, Randomized, Double-Blind, Parallel-Group and active Controlled Study to
Evaluate the Effect of QVA149 (110/50 ug o.d.) vs NVA237 (50 ug o.d.) and Open Label Tiotropium (18 ug o.d.)
on COPD exacerbations in Patients with Severe to very Severe COPD October 2010-October 2011
A 26-week Treatment, Multi-Center, Randomized, Double-Blind, Parallel-Group and active Controlled (open
label) Study to assess the efficacy, safety and tolerability of QVA149 (110/50 ug o.d.) in Patients with Moderate
to Severe COPD May–October 2011
Utsuka
4. Objectives:
Review GINA 2014 guidelines on Asthma
Review the GOLD 2014 guidelines on COPD
Epidemiology
Pathophysiology
Signs and symptoms
Diagnosis
Treatment
Approach to a patient with ACOS (Asthma-COPD
Overlap Syndrome) GINA 2014
5. CASE 1
19 year old female student
CC: 3 days cough, wheezing, SOB
Precipitated by exercise (frisbee)
Relieved by salbutamol nebulization (past 3 nights)
Self medicated with prednisone 10mg 1 dose
(+) history of asthma attacks during childhood
(+) family Hx of asthma (mother)
(+) Hx of atopy and (+) allergy to crustaceans
PE: talks in sentences with occasional wheeze
6. Asthma
A reversible obstructive airway disease due to bronchial muscle constriction
and airway inflammation; characterized by cough, wheezing and shortness of
breath.
Resolves spontaneously or with use of rescue meds.
Exacerbations are caused by triggers.
1 of 10 Filipino adults
3 of 10 Filipino Children
7. ASTHMA – levels of control
Characteristic Controlled Partly controlled Uncontrolled
Daytime symptoms:
wheezing, cough, SOB
None >2x/week >3x/week
Limitation of activities none any any
Nocturnal awakening none any any
Need for reliever meds < 2x / wk >2x/wk >2x/week
8. ACT – ASTHMA CONTROL TEST
< 20 – suggests poor Asthma control
9. ACT – ASTHMA CONTROL TEST
< 20 – suggests poor Asthma control
10. Diagnostics
Spirometry – measures certain lung volumes; useful in diagnosing
obstructive lung patterns
Peak flow – screening test; measures maximum speed of expiration
14. Treatment
· Patient education
· Inhaler technique and adherence to medications
STEP 1 STEP 2 STEP 3 STEP 4 STEP 5
Preferred
Controller
Choice
NONE Low Dose ICS
(Inhaled Steroid)
Low dose
ICS-LABA
(ADEFLO)
Medium/High
ICS-LABA
(ADEFLO)
Refer for add
on treatment
(anti-IgE)
Other
Controller
Options
-- LTRA or
methylxanthines
(montileukast
Or Theophylline)
Medium/High
ICS-LABA OR
Low dose
ICS/LABA + LTRA
or /+ Theophylline
High Dose
ICS-LABA +
LTRA or
Theophylline
Low dose oral
steroid
RELIEVER SABA – short acting B2-agonist (Salbutamol)
15. Strategies to ensure effective use of
inhaler devices
2014
CHOOSE
Most appropriate device
The medication needed
Available devices
Cost
Patient skills and patient’s choice
Ensure no physical barriers, e.g. arthritis
Avoid use of multiple different inhaler
types to avoid confusion
16. Strategies to ensure effective use of
inhaler devices 2014
Clinicians should be able to demonstrate correct technique for each of
the inhalers they prescribe
For MDIs - use a spacer
Improves delivery
Reduces potential
side-effects of ICS
17. Home meds and plans:
Inhaled corticosteroid
May add oral steroid for 3-5 days
Round the clock reliever use for a few days then give on PRN basis
If symptoms worsen :
Follow-up in 3-5 days with chest X-ray
Assess other possible causes of exacerbation
Follow-up 2 weeks – 1 month after consult
Measure peak flow on succeeding visits
6-12 months of ICS therapy
18. Case 2:
72 year old housewife
CC: on and off cough, wheezing, shortness of breath
Relieved by salbutamol nebulization
lately is more bothersome after hosting a birthday party
with grayish sputum, difficulty sleeping
Has consulted several doctors; has 4 inhaler devices
Passive smoker
Previously hospitalized due to asthma 3 months ago
PE: talks in phrases, (+) wheezing both lung fields
19. Case 2:
Inhalers:
77 female smoker
•Tiotropium handihaler LAMA
•Salbutamol MDI SABA
•Procaterol swinghaler SABA
•Formoterol + Budesonide turbohaler ICS-LABA
•Budesonide turbohaler ICS
26. Acute exacerbation in COPD
Increased symptoms
Reduced lung function
Accelerate lung function
decline
Deteriorate quality of life
Increased economic cost
Increased mortality
“an acute event characterized by
worsening of respiratory symptoms
that is beyond normal day-to-day
variations and leads to a change in
medication.”
Impact of
acute
exacerabatio
ns in COPD
GOLD Strategy Document 2014 (http://www.goldcopd.org/)
30. COPD Assessment Test : CAT
I never cough I cough all the time
I have no phlegm (mucus) in my chest at all My chest is full of phlegm
My chest does not feel tight at all My chest feels very tight
When I walk up a hill or one flight When I walk up a hill or one flight
of stairs I am not breathless of stairs I am very breathless
I am not limited doing any activities at home I am very limited doing activities at home
I am confident leaving my home despite my I am not at all confident leaving my
home lung condition because of my lung condition
I sleep soundly I don't sleep soundly because of
my lung condition
I have lots of energy I have no energy at all
31. COPD Assessment Test : CAT
I never cough I cough all the time
I have no phlegm (mucus) in my chest at all My chest is full of phlegm
My chest does not feel tight at all My chest feels very tight
When I walk up a hill or one flight When I walk up a hill or one flight
of stairs I am not breathless of stairs I am very breathless
I am not limited doing any activities at home I am very limited doing activities at home
I am confident leaving my home despite my I am not at all confident leaving my
home lung condition because of my lung condition
I sleep soundly I don't sleep soundly because of
my lung condition
SCORE: 35
I have lots of energy I have no energy at all
34. COPD treatment: 2 MAIN GOALS
Goals for treatment of stable COPD
Relieve symptoms
Improve exercise tolerance
Improve health status
And
Prevent disease progression
Prevent and treat exacerbations
Reduce mortality
REDUCE
SYMPTOMS
REDUCE
RISK
of exacerbation
Global Strategy for the Diagnosis, Management and Prevention of COPD
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2014
35. THERAPEUTIC OPTIONS
What is the single most effective intervention
to slow the progression of COPD?
1
Home
Oxygen
2
Pulmonary
Rehab.
3
Smoking
Cessation
4
Flu
Vaccination
Evidence A
36. How to start Treatment*
Newly Diagnosed COPD Patient
Active Reduction of Risk Factors
1. Smoking Cessation
2. Vaccination- Yearly Influenza ; Pneumococcal Vaccine every 5 years
As Needed SABA or SABA/SAMA or if patient may benefit from OD/ bid treatment use
LABA or LAMA
Assess : symptoms and RISK:
Pulmonary Rehabilitation
Long Acting Bronchodilator
LABA alone (indacaterol) or LAMA alone (Tiotropium)
Assess: More Symptoms low Exacerbation Risk
Add another Long acting bronchodilator
LABA + LAMA or LAMA + LABA
Assess: More Symptoms, High Exacerbation Risk
Progressive & Frequent Exacerbation
+ ICS
LAMA + LABA + ICS
Adjunctive: Pulmonary rehabilitation, O2 treatment Surgical Options
•Based on Pharmacologic first choice treatment,
GOLD 2011
• other treatment options available.
37. ICS- inhaled steroid: fluticasone/budesonide/beclomethasone
SABA – Salbutamol; SAMA – Ipatropium; LABA – Indacaterol; LAMA- Tiotropium
SABA+SAMA – Salbu+IpBr (Pulmodual) OR *ICS+LABA – Fluticasone+Salmeterol (Adeflo)
38. Pharmacological Management of COPD
Patient First Choice Second Choice Alternative Choice
SABA or SAMA prn SABA and SAMA
A
LABA or LAMA
Theophylline
(Option: Doxofylline )
B
Pulmodual Dilatair
LABA or LAMA LABA and LAMA
SABA and /or SAMA
Theophylline
(Option: Doxofylline )
C
ICS +LABA or LAMA LABA and LAMA
Dilatair
PDE4 Inhibitor
SABA and/ or SAMA
Theophylline
(Option: Doxofylline )
D
ICS+ LABA and LAMA
ICS + LAMA
ICS + LABA + LAMA
ICS and LABA and PDE 4 inh
LABA + LAMA
LAMA + PDE 4 inh
Dilatair
Carbocisteine
SABA and/ or SAMA
Theophylline
(Option: Doxofylline )
Dilatair
Adeflo
Adeflo
39. GUIDED ASTHMA SELF-MANAGEMENT
EDUCATION AND SKILLS TRAINING
2014
Inhaler use is a skill - must be learned and
maintained
Up to 70–80% are unable to use their inhaler
correctly.
Unfortunately, many health care providers are unable
to correctly demonstrate how to use the inhalers they
prescribe
Most people with incorrect technique are unaware
that they have a problem
There is no ‘perfect’ inhaler - patients can have
problems using any inhaler device
40. Strategies to ensure effective use of
inhaler devices 2014
Clinicians should be able to demonstrate correct technique for each of
the inhalers they prescribe
For MDIs - use a spacer
Improves delivery
Reduces potential
side-effects of ICS
41. A New Twist to
FDC ICS-LABA Inhaler
Therapy
Twist
Miat Monodose DPI
42. Salmeterol xinafoate/ Fluticasone
propionate (Adeflo) via Adehaler
Passive DPI (aerolizer)
breath actuated
compact, portable, easy to use
no hand-mouth coordination
required
Inhalation by capsule loaded by the
patient
40 capsules/ box
Lactose carrier
IFR > 60 lpm; no breath hold
Protect from humidity
Sims MW. Chest 140(3):781–788, 2011.
Laube BL, ERS/ISAM Task Force on Inhalational Therapy. Eur Respir J 37: 1308–1331, 2011.
Labris NR, Dolovich MB. Br J Clin Pharmacol 56: , 600–612, 2003.
50/250 mcg
50/500 mcg
46. Case 3
55 year old, male, teacher
CC: cough, wheezing, shortness of breath 7 days
Precipitated by exposure to dust (he rides a motorbike)
Sneezing, itchy throat
Unable to sleep due to SOB, partially relieved by salbu neb
(+) history of childhood asthma
(+) 20 pack year (current) smoker
(+) history of antibiotic (Co-amox) intake 4 weeks ago after diagnosed with
pneumonia as outpatient.
PE: talks in sentences, (+) wheezing both lung fields
47. What will you give to this patient?
A. SABA (Salbutamol PRN)
B. ICS (Budesonide)
C. LAMA (Tiotropium)
D. LABA (Indacaterol)
E. ICS+LABA (Fluticasone + Salmeterol)
51. For a patient, count the
number of checked boxes in
each column. If 3 or more
are checked for either
asthma or COPD , that
diagnosis is suggested. But
if there are similar numbers
of checked boxes in each
column, ACOS should be
considered.
55. Approach to ACOS
(Asthma-COPD Overlap Syndrome)
Asthma >> ICS (Inhaled corticosteroid)
COPD >> LABA (long acting B2 agonist)
ACOS >> ICS + LABA
56. Approach to ACOS
(Asthma-COPD Overlap Syndrome)
At least among adults, ACOS might represent a severe form of asthma,
characterized by greater risk of hospitalizations and exacerbations
ACOS is likely the result of early asthma that has progressed to fixed
airway obstruction because airway remodeling and of its interaction
with smoking
Treatment may prevent a steeper decline of lung function among
ACOS.
De Marie Et. Al. ERS 2013 Presentation
59. SMOKER'S PRAYER
Heavenly Father, hear my plea,
and grant my lungs serenity.
Give me strength to kick the smoking
that's been causing all my choking.
Let my breath be fresh and clean
without a trace of nicotine.
Each ciggie I smoke so often
Adds another nail in my coffin
Guide me Lord, by Your holy means
past all those cigarette machines.
It hurts to hear My Loved ones say
kissing ya's like lickin' an ashtray.
Please oh Lord, Hear my voice,
give me will power, while I have a choice.
I ask Your help and it's no wonder
because if I don't quit, I'm six feet under.