2 - COPD Flashcards
List 4 obvious statements about COPD therapy
- Benefits should be greater than harms
- Newer isn’t necessarily better
- Only combine things if both are necessary
- Patient engagement is essential to care
List 5 things that influence COPD realms
1) CPGs (clinical practice guidelines)
2) Clinical inertia (you get stuck in the way that you’ve always done things, especially if you haven’t seen visible harms but this doesn’t mean it’s the best care
3) Heuristics (clinical rules of thumb)
4) Wanting to do something (want to provide “better care” not necessarily “more care”)
5) Industry
Describe the prevalence of COPD in Canada
4% of people > 35 age REPORT a diagnosis
*this would be a lot higher if you performed spirometry on all previous smokers
Describe the mortality of COPD in Canada
4th leading cause of death
Describe the morbidity of COPD in Canada
- 45% report overall health as “fair or poor”
- 33% report health as “somewhat worse or much worse” than a year ago
- 21% report that breathing problems affect their life “quite a bit or extremely”
Describe the economic burden of COPD in Canada
- 3% of all hospitalizations (8% report a hospitalization)
- Average hospital stay of 10 days = $10,000
23-33% of patients hospitalized with a COPD exacerbation die within ___ year
1
In hospital mortality rate for COPD exacerbations is ___%
8-11
25-38% of patients die within 1 year of a first _____ _____
myocardial infarct
In hospital acute MI mortality rate is ______%
8-9.4
Do we have any medications that reduce mortality for people with COPD ?
NO
___ is the only common cause of death that has increased in prevalence over the last 40 years in developed countries.
COPD
List some things that smoking is a risk factor for
- osteoporosis
- lung cancer
- heart attack
- stroke
- COPD !!!!
Age of onset for asthma
Usually < 40 years
Age of onset for COPD
Usually > 40 years
Smoking history for asthma
Not causal
Smoking history for COPD
Usually > 10 pack years
Sputum production in asthma ?
Infrequent
Sputum production in COPD ?
Often
Allergies with asthma?
Often
Allergies with COPD?
Infrequent
Disease course with Asthma
stable (with exacerbations)
Disease course with COPD
progressive worsening (with exacerbations)
Clinical symptoms with asthma
intermittent & variable
Clinical symptoms with COPD
persistent
Spirometry with asthma
usually normalizes
Spirometry with COPD
never normalizes
Describe COPD
- it is persistent and progressive
- gets worse, then gets better but will never be normal and will continue to decline
Describe reversible COPD symptoms
main target of medications
- Presence of mucus and inflammatory cells and mediators in bronchial secretions
- Bronchial smooth muscle contraction in peripheral and central airways
- Dynamic hyperinflation during exercise
Describe irreversible COPD symptoms
- Fibrosis and narrowing of airways
- Reduced elastic recoil with loss of alveolar surface area
- Destruction of alveolar support with reduced potency of small airways
What is FEV1?
Force expiratory volume over a second (as fast as you can blow over a second)
What is the single most effective way to reduce decline in lung function?
smoking cessation !!!!
All patients with suspected COPD should have their lung function assessed by ______
spirometry
A post-bronchodilator FEV1/FVC ratio of ______ defines airflow obstruction that is not fully reversible, and is necessary to establish a diagnosis of COPD
70% or 0.7
What spirometry values (FEV1 and FEV1/FC) would indicate mild COPD?
FEV1 > 80% predicted
FEV1/FVC < 0.7
What spirometry values (FEV1 and FEV1/FC) would indicate moderate COPD?
50% < FEV1 < 80% predicted
FEV1/FC < 0.7
What spirometry values (FEV1 and FEV1/FC) would indicate severe COPD?
30% < FEV1 < 80% predicted
FEV1/FVC < 0.7
Describe the long-term management of mild COPD based on 2017 guidelines
SABA prn
then (if worsening)
LAMA or LABA
Describe the long-term management of moderate COPD (infrequent exacerbations) based on 2017 guidelines
LAMA or LABA then (if worsening) LABA/LAMA then (if worsening) LAMA + ICS/LABA
Describe the long-term management of severe COPD (frequent or severe exacerbations) based on 2017 guidelines
LAMA/LABA then LAMA + ICS/LABA then \+ PDE4 inhibitor (+/- macrolide +/- mucolytic)
Describe the long-term management of COPD w asthma based on 2017 guidelines
Low-moderate dose of ICS/LABA
then
Add LAMA and/or increase dose of ICS/LABA
What outcomes are important for you and your patients?
- improving QOL (reducing use of rescue meds, allowing patient to do the activities they like)
- FEV1
- reduce hospitalizations
- prevent progression of disease
- dyspnea scores
- walking distance
- reduce exacerbations
- mortality
What is statistical significance?
- Establishing that the difference shown is not (or very unlikely) due to chance
- The more patients you have in a study, the greater your ability to show a small statistical difference, if it exists
What is clinical significance (or relevance) ?
- Is the result significant to you and the patient?
- SGRQ (St. George Respiratory Questionnaire) - a scale of 0-100 with a change of 4 points considered clinically relevant
- FEV1 (a change of 10% or 100-120 mL is considered clinically relevant)
Does a statistically positive result equal a clinically meaningful result?
No - not always !!!
What things do you want to ask about if someone says they’re inhaler isn’t working
- technique?
- adherence?
- did they have a cold?
- did they know what to expect? (ex. ipratropoium works in 5-15 mins, tiatropium will work in a big longer)
- they may think it’s not working if they’re expecting the wrong result
Other than SABDs, what 2 types of “acute” medications might we consider giving him (he has dyspnea, cough, yellow-green sputum, increasing cough over the last couple days)?
antibiotics and steroids
Antibiotic Treatment Recommendations:
What makes a case “simple”?
<4 exacerbations/year and at least 2 of the following:
- increased sputum purulence
- increased sputum volume
- increased dyspnea
Antibiotic Treatment Recommendations:
What makes a case “complicated”?
>4 exacerbations/year and at least 2 of the following: -increased sputum purulence -increased sputum volume -increased dyspnea OR -failure of first line agents above OR -antibiotics in the past 3 months
What are the first line antibiotic agents for simple case of an acute exacerbation of COPD?
- amoxicillin 1 g PO TID
- doxycycline 200mg PO once, then 100mg PO BID
- Sulfa/trim 1 DS (800/160) tablet PO BID
**treat for 5-7 days. Evidence indicates that 5 days of treatment may be as effective as 7-10 days.
What are the first line antibiotic agents for complex case of an acute exacerbation of COPD?
- amox-clav 875/125 mg PO BID for 5-10 days
- cefuroxime axetil 500-1000mg PO BID for 5-10 days
- levofloxacin 750 mg PO once daily for 5 days
What are the ALTERNATIVE antibiotic agents for complex case of an acute exacerbation of COPD?
- azithromycin 500mg PO daily x 3 days
- clarithromycin 500mg PO BID or 1000mg extended release PO once daily for 5-10 days
What defines failure of first line agents?
- no improvement in symptoms following completion of antibiotic therapy OR clinical deterioration after 72 hours of antibiotic therapy
- use a different AB class than was used previously
Due to the broad spectrum of levofloxacin, potential for increases resistance and risk of __________ infection, reserve this medication for B-lactam allergies or failure to first line antibiotic therapy
C. dif
Macrolide have poor Haemophilus coverage and significant S. pneumoniae resistance. The benefit of macrolide may be due more to ____________ properties than to antibacterial activity.
anti-inflammatory
Describe the efficacy of using systemic steroids in AECOPD
- significant increase FEV1 (>20%) in 5/8 studies
- decrease in treatment failure in several studies
What dose of systemic steroids is used in AECOPD?
Very wide range studied ( 20 mg - 150 mg prednisone equivalent)
What is the duration of systemic steroids used in AECOPD?
- Up to 2 weeks
- Largest trial (SCOPE) showed largest benefit (FEV1) at 3 days
- 2 studies showed most effect in 5 days with little improvement beyond
What is usually done (drug, dose, duration) for using a systemic steroid for an AECOPD?
Prednisone 50 mg x 5 days
Is a taper required of short term systemic steroids?
Nope
What are some SE of tiotropium ? (LAMA)
- dry mouth
* don’t spray in eyes especially if you have glaucoma lmao
What are some SE of salmeterol ? (LABA)
- tremors
- nervousness
- tachycardia
When comparing Tiotropium (LAMA) vs. Salmeterol (LABA), what were the results?
- Less moderate exacerbations
- Less patients have > 1 exacerbation
- Less hospitalizations
- Less side effects (see previous cards)
What does the latest CPG recommend when either using a LAMA or a LABA ?
“We recommend the use of an inhaled long-acting bronchodilator, either LAMA or LABA mono therapy, to reduce dyspnea, improve exercise tolerance and improve health status in stable COPD patients”
*can use either, so cost or frequency would be what would sway patients toward either one
List LAMA’s
- Glycopyrronium
- Tiotropium
- Aclidinium
- Umeclidinium
How do the other LAMAs compare to the standard that we’ve been using for > 10 years (tiotropium) ?
- All have efficacy over placebo
- They either show no difference compared to tiotropium or having been studied.
- Cost of all of them are similar
- Patient may care about what type of inhaler and prefer one over the other.
List LABA’s
- indacaterol
- formoterol
- salmeterol
How do the LABA’s compare to each other
- indacaterol is once daily
- formoterol and salmeterol are BID
- formoterol has a little bit more of a fast onset of action
*again, pretty much all the same, depends what type of inhaler the patient wants and frequency of inhalations per day
Joan is on glycopyronnnium (LAMA), but she can no longer do grocery shopping without having to us multiple doses of her SABD (short acting bronchodilator), what are possible next steps for Joan?
According to the guidelines it is to use both LAMA/LABA together.
What is the idea that using LAMA/LABA together is better than just one of them?
2 mechanisms of action:
- Relaxation of airway smooth muscle by direct inhibition of cholinergic activity (LAMA)
- Antagonism of bronchoconstriction via B2 adrenergic pathways (LABA)
List the new LAMA/LABA combos that are out there
- Glycopyrronium (LAMA) + Indacaterol (LABA)
- Umeclidinium (LAMA) + Vilanterol (LABA)
- Aclidinium (LAMA) + Formoterol (LABA)
- Tiotropium (LAMA) + Olodaterol (LABA)
What is TDI?
Transition Dyspnea Index (TDI) - an evaluative instrument that measures changes in dyspnea compared to the initial or baseline state
- 3 to +3 for Changes in functional impairment
- 3 to +3 for Changes in magnitude of task
- 3 to +3 for Changes in magnitude of effort
-9 to +9 overall 18 point score
How big of a change in TDI (transition dyspnea index) would you want to see?
Minimally clinically important difference (MCID) = 1
so a change of 1 point is considered significant
Is LAMA + LABA better than just LAMA or LABA ?
- 1 or more exacerbations
- less rescue puffs
- no difference in hospitalizations
- no difference in adverse events
*a little improvement but not really ? I don’t really know
What are our patient’s desired outcomes?
- Dyspnea
- Exercise tolerance
- Rescue inhaler use
- should change in 2-4 weeks
- QOL
- this is multifactorial, takes longer to determine (weeks - months)
- Exacerbations/hospitalizations
- may take years to determine in some cases
What is the rule of thumb for undertaking a combo trial ?
- If successful, a combo inhaler is much less expensive than two separate inhalers
- If not successful, STOP
*it’s all about if it works for the patient, because studies show minimal benefit so it may or may not provide benefit for your specific patient.
Other than quitting smoking, what is the best intervention ?
pulmonary rehab
What is pulmonary rehab?
Multidisciplinary team providing:
-Education, smoking cessation, exercise training, nutrition counselling, psychosocial support x 6-8 weeks
Who is pulmonary rehab aimed at?
- Any patient’s who’s COPD symptoms are disabling
- Most of the evidence is for patients who have a FEV1<50%
Describe the benefits of pulmonary rehab
Improvements in:
- Overall dyspnea severity
- Exertional dyspnea/walking test
- Health-related QOL
Also have significant improvement in hospitalization and mortality
What is the problem with adding ICS to COPD patients?
increases risk/incidence of pneumonia
“We suggest that stable COPD patients without ACO (asthma component) who have persistently poor health status despite the regular use of a LABA, to ‘step up’ therapy to an inhaled LAMA plus LABA dual therapy rather than to an inhaled ICS/LABA combination”
“There is insufficient evidence in stable COPD patients to determine whether inhaled LAMA plus ICS/LABA triple therapy confers additional benefit to inhaled LAMA plus LABA dual therapy in reducing dyspnea, improving exercise tolerance and activity levels, or improving health status. However, in stable COPD patients with high symptom burden and poor health status despite the use of inhaled LAMA plus LABA dual therapy, strap up of treatment to LABA plus ICS/LABA triple therapy may be considered”
It has CB grading (conditional) - therefore it can be considered for those who are really severe/uncontrolled.
List some adherence factors comparing trials and reality
- Adherence rates in clinical trials (as high as 70-90%
- Adherence rates in clinical practise (as low as 30%)
What does the patient need to know?
1) Benefits:
- Do they know the magnitude of effect?
- What’s important to them?
- Are they perceiving a benefit?
2) Harms:
- If harms exist (they usually do), do they know how to manage them?
3) Cost
4) How to use the inhaler properly
Principles & Practical Tips:
_____ medications generally don’t show massive improvements, but they can have noticeable and important benefits for patients
COPD
Principles & Practical Tips:
Be sure to allow for patient ______
preference
Principles & Practical Tips:
Add inhalers ___ at a time to assess for true effect
one
Principles & Practical Tips:
If symptom improvements are not optimal on ______ after a few months, a trial of a LAMA (or LABA) is justified
ipratropium
Principles & Practical Tips:
If combining _____ & _____, make sure patient is getting symptom benefit from both
LAMA & LABA
Principles & Practical Tips:
Unless ____ is present as well, ICS use is rarely justified
asthma
Principles & Practical Tips:
If a patient is already on an ICS, when is a good indication to stop it?
no additional benefit (ex. over 6 months to 1 year) or has several pneumonias, this is a good indication to stop it
