Management of COPD Updates and Evidence Providence Alaska Medical - PowerPoint PPT Presentation

Management of COPD Updates and Evidence Providence Alaska Medical Center PGY1 Pharmacy Practice Residents Ann-Chee Cheng, PharmD Kaite Kammers, PharmD http://www.fpnotebook.com/_media/lungXsGrayBB962.gif

Disclosures All presenters of this activity have no financial relationships relevant to this activity ●

Objectives 1. Describe the updated recommendations in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD 2. Compare and contrast therapies for management of COPD based on evidence from recent clinical trials 3. Develop a management plan for COPD using 2017 GOLD guidelines

Pre-Test 1. Which inhaled medication is no longer a preferred agent in the management of COPD? 2. Which inhaled medication(s) is now emphasized/ preferred in all ABCD severity groups? 3. What class of medications was added to step-up therapy for an exacerbation in a group D patient? 4. What are goals of treatment for improving inhaler technique? 5. Based on results from the FLAME study, which combination of inhaled medications lengthened time between exacerbations? 6. What did the results of the WISDOM study show in relation to withdrawing ICS from patients on triple therapy? 7. What population(s) was shown to benefit most from adding roflumilast to maintenance therapy? 8. What should be assessed in regard to medication use in all patients prior to escalating therapy in COPD?

COPD Death Rates in the United States Thun MJ, Carter BD, Feskanich D, et al. 50-year trends in smoking-related mortality in the United States. N Engl J Med. 2013;368(4):351-64.

Revisions to the GOLD Guidelines Updated the definition of COPD ● Separated GOLD category from COPD severity group ● Added long-acting muscarinic antagonist (LAMA) and long-acting ● beta2 agonist (LABA) to mild COPD patients Removed inhaled corticosteroids (ICS) as preferred agents in the group ● C and D Added azithromycin and erythromycin as alternative agents ● Emphasized inhaler technique teaching ● Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

Definition of COPD ● Common, preventable , and treatable pulmonary disease ● Persistent respiratory symptoms and airflow limitation due to airway and/or alveolar abnormalities Usually caused by interaction of significant exposure to noxious ● particles gases and specific host factors Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

Question 1: Which of the following GOLD grades and severity groups are appropriate for a 65- year old with COPD Assessment Test (CAT) score of 28 today, not COPD exacerbations in the past year and forced expiratory volume in 1 second (FEV1) of 29% of the predicted value 1 month ago? A. GOLD grade 4, group B B. GOLD grade 4, group D C. GOLD grade 1, group A D. GOLD grade 1, group C

Severity of Airflow Limitation - GOLD Grades Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

2016 GOLD Guidelines Severity Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2016. www.goldcopd.org.

2017 GOLD Guidelines Severity Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

COPD Assessment based on GOLD 2017 1. Use Spirometry to diagnose COPD and assess airflow limitation (GOLD grade) 2. Use CAT or mMRC to assess COPD symptom severity 3. Determine exacerbation risk : a. Number of COPD exacerbations in past 12 months b. Number of COPD-related hospitalizations in the past year

Question 2: Which of the following types of medications are currently recommended for a 45-year old with one COPD-related hospitalization in the past year, a CAT score of 28 and a FEV1 49% and the predicted value with no airway reversibility who is using an albuterol metered-dose inhaler (MDI) 90 mcg 2 puffs 3 - 4 times/ day for COPD symptoms? A. Tiotropium/ Olodaterol B. Budesonide/ Formoterol C. Fluticasone/ Umeclidinium/Vilanterol D. Ipratropium/ Albuterol

2016 GOLD: Initial Medications Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2016. www.goldcopd.org.

2017 GOLD: Initial Medications Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

Question 3: Which of the following step-up options is recommended for a 75-year old woman with GOLD grade 4, group D COPD currently taking ICS/LABA and a LAMA? She is adherent to her inhalers and is able to use them correctly. She is on 2L of oxygen/ 24 hours. She continues to have a CAT score of 30 and a COPD exacerbation every other month. Despite quitting smoking 1 year ago, she is losing weight and complains of feeling depressed. A. Azithromycin B. Roflumilast C. Theophylline D. Prednisone

Step-up / Alternative Medications 2016 2017 LAMA and/or LABA and/or ICS LAMA and/or LABA combination ● ● combinations LABA + ICS ● SAMA + SABA LAMA + LABA + ICS ● ● Theophylline Step-up: ● ● Roflumilast + LAMA Roflumilast ● ○ Roflumilast + LABA Azithromycin ● ○ ICS + LABA + roflumilast Erythromycin ● ○ Other: ● ICS withdrawal? ○ Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

Azithromycin and Erythromycin Decreased exacerbations when used for 6 -12 months ● No significant decrease in hospitalizations or overall mortality ● Increased side-effects ● Unknowns: ● Optimal dosing ○ Duration of therapy (no data past 12 months) ○ Subpopulations with the most benefit ○ Ni W, Shao X, Cai X, et al. Prophylactic use of macrolide antibiotics for the prevention of chronic obstructive pulmonary disease exacerbation: a meta-analysis. PLoS ONE. 2015;10(3):e0121257.

ICS Withdrawal Mixed data on if w/d increases lung function and/or decreases ● exacerbations Background use of LAMA or LABA may minimize effect ● Modest decrease in FEV1 (~ 40mL) ● Magnussen H, Disse B, Rodriguez-roisin R, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med. 2014;371(14):1285-94. Watz H, Tetzlaff K, Wouters EF, et al. Blood eosinophil count and exacerbations in severe chronic obstructive pulmonary disease after withdrawal of inhaled corticosteroids: a post-hoc analysis of the WISDOM trial. Lancet Respir Med. 2016;4(5):390-8.

Triple Inhaled Therapy LABA + LAMA + ICS = triple inhaled therapy ● Fluticasone furoate + umeclidinium + vilanterol 100 mcg/62.5 mcg/ 25 ○ mcg (Trelegy Ellipta ™ ) daily -- approved September 2017 Add LAMA to existing LABA/ICS regimen improves lung function and patient ● reported exacerbations Single study found no benefit of adding ICS to LABA/LAMA combination ● More evidence needed if triple inhaled therapy is more beneficial than ● LABA/LAMA alone Brusselle G, Price D, Gruffydd-jones K, et al. The inevitable drift to triple therapy in COPD: an analysis of prescribing pathways in the UK. Int J Chron Obstruct Pulmon Dis. 2015;10:2207-17. Aaron SD, Vandemheen KL, Fergusson D, et al. Tiotropium in combination with placebo, salmeterol, or fluticasone-salmeterol for treatment of chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2007;146(8):545-55.

Question 4: A 55-year old with COPD returns to clinic with questions about the proper use of his Respimat inhaler. Which of the following techniques is correct for the use of this inhaler? A. Priming the inhaler before the first use B. Opening the cap and then twisting the base C. Placing the mouthpiece 2 finger spaces away from the mouth D. Inhaling use a quick and steady breath

Critical Errors with Inhalers Van der palen J, Thomas M, Chrystyn H, et al. A randomised open-label cross-over study of inhaler errors, preference and time to achieve correct inhaler use in patients with COPD or asthma: comparison of ELLIPTA with other inhaler devices. NPJ Prim Care Respir Med. 2016;26:16079.

Question 5: A COPD patient reports a history of intolerance to propellants in inhalers. Which of the following inhalation delivery systems uses a propellant? A. Metered-dose inhaler B. Dry powder inhaler C. Jet nebulizer D. Propellants are no longer used inhalation devices

Goals of Treatment with Inhaler Emphasis Reduce risk ● Reduce symptoms ● Personalized ● Inhaler improvement: ● Facilitate drug deliver ○ Reduce frequency ○ Minimize number of inhalers ○ Still the same drug classes…. ○ Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.