COPD and Asthma Update

Asthma and COPD

How can you make a difference?

Disclosures

• Jo Congleton

• Consultant in Integrated Respiratory Care BSUH/SCFT

• Over the past few years I have given presentations at meetings and run educational training sessions for AstraZeneca and Boehringer Ingelheim

Overview

• What is asthma?• Current themes in treatment

• What is COPD?• Current themes in treatment

• Non-pharmacological treatments

• How can you contribute to management?

Medications Cost June 2012

Of the top 5 costliest drugs to the NHS, ALL are respiratory inhalers

• 5. Seretide 125 evohaler - £81 million/yr

• 4. Seretide 500 accuhaler - £85 million/yr

• 3. Symbicort 200 - £90 million/yr

• 2. Tiotropium - £120 million/yr

• 1. Seretide 250 evohaler - £180 million/yr

Airways narrowing due to

bronchoconstriction and

inflammation; duration and

severity are risk factors for

development of airway

remodelling and COPD

Airways collapse due to

destruction of alveolar walls

– may lead to bullae


Chronic irritation of the bronchi causing

inflammation and changes to the mucociliary

escalator; often results in chronic cough

Large airway

inflammation

Small

airwaysEmphysema

Fibrosis

Definition of COPD

COPD is predominantly caused by smoking and is characterised by

airflow obstruction that is not fully reversible

The airflow obstruction does not change markedly over several

months but is usually progressive in the long term

Exacerbations often occur, when there is a rapid and sustained

worsening of the patient’s symptoms beyond normal day-to-day

variations

NICE 2010

Definition of Asthma

• Asthma is a chronic inflammatory condition characterised by variable and reversible airway obstruction

• Eosinophilic bronchitis


bronchoconstriction and

inflammation; duration and

severity are risk factors for

development of airway

remodelling and COPD

Airways collapse due to

destruction of alveolar walls

– may lead to bullae


Chronic irritation of the bronchi causing

inflammation and changes to the mucociliary

escalator; often results in chronic cough

Large airway

inflammation

Small

airwaysEmphysema

Fibrosis

DiagnosisPatients over 35

Smokers or ex-smokers

With any of the following:

exertional breathlessness

chronic cough

regular sputum production,

frequent winter ‘bronchitis’

wheeze

C

O

P

D

NICE COPD Guidelines 2010

Diagnosis

Patients over 35

And no clinical features of asthma




chronic cough



wheeze

C

O

P

D


• Wheezy Child

• DV PEFR chart

• Day to day variation

• b2 reversibility

• Steroid reversibility

• Atopy, Family History

SMOKERS CAN HAVE ASTHMA

• Onset 35- 55yrs

• Flat PEFR chart

• Constant symptoms

• Progressive SOB

• Little / no reversibility

• Significant smoking history

ATOPICS CAN HAVE COPD

Does my patient have asthma or COPD?

Asthma COPD Overlap Syndrome? (ACOS)

• Many patients have features of asthma and COPD

• Older age group• Childhood asthma


Other diagnoses to consider

• Bronchiectasis

• ILD

• Dysfunctional Breathing/Vocal cord dysfunction

• Heart Failure

Case VK

►68 year man

►Cough and SOB

►Cough 18 years, worse recently, egg cup of green sputum per day

►Breathlessness varies day to day

►Even a good day ex tol 30 yds

►Smoking History: 30 pk yrs, nil for 20 yrs

CASE VK

• Treatment had been escalated

• Now on ‘triple thereapy’

• ICS component high dose

• No significant response to treatment

Asthma Management

• New BTS/SIGN guideliines

Inhaled steroid use and Asthma Death

0

0.5

1

1.5

2

2.5

0 1 2 3 4 5 6 7 8 9 10 11 12

No. of canisters of inhaled

corticosteroids per year

RR Death fromAsthma

Moving up and moving down

Adapted from British guideline on the management of asthma. 2016. Available from: https://www.brit-thoracic.org.uk/document-library/clinical-

information/asthma/btssign-asthma-guideline-quick-reference-guide-2016/ (accessed Oct 2016)

• Initial add on therapy:• LABA plus low dose ICS – usually combination

• Consider maintenance and reliever therapy

• Additional add on therapies• Stop LABA and move to medium dose ICS

• Continue LABA, move to medium dose ICS

• Continue LABA/ICS and trial LTRA

• Continue LABA/ICS and trial SR theophylline

• Continue LABA/ICS and trial LAMA (unlicensed)



Consider moving up therapy if using 3 or more doses

of rescue β2 per week

ICS Doses

• Low: Beclometasone 100mcg 2puffs bd

• Medium: Beclometasone 200mcg 2 puffs bd

• High Dose: Beclometasone 200mcg 4 puffs bd



High dose therapies

• High dose ICS

• Addition of a 4th drug:• LTRA

• SR theophylline

• Beta agonist tablet

• LAMA

• REFER PATIENT FOR SPECIALIST CARE

Adapted from British guideline on the management of asthma. 2016. Available from: https://www.brit-thoracic.org.uk/document-

library/clinical-information/asthma/btssign-asthma-guideline-quick-reference-guide-2016/ (accessed Oct 2016)

COPD Management

• Aim of treatment:

to relieve symptoms

reduce the risk of exacerbations

• Reduce risk of death

QoF COPD Cases: B+H CCG (predicted 10,711)

3400

3500

3600

3700

3800

3900

4000

COPD

2011/12

2012/13

2013/14

2014/15

Private and confidential

27

Case FindingPatients over 35




chronic cough



wheeze

C

O

P

D


COPD Management

• Relieve Symptoms

• Reduce Risk of Exacerbations

• Reduce risk of death

• Bronchodilators

• Pulmonary Rehabilitation

• LABA/ICS

• Bronchodilators

• Pulmonary Rehabilitation

• Smoking Cessation

• Smoking Cessation

• LTOT

Risk Symptoms Exacerbations

High risk, less symptoms

ICS/LABA or LAMA

High risk, more symptoms

ICS/LABA

(triple therapy)

Low risk, less symptoms

SABA or SAMA

(LABA or LAMA)

Low risk, more symptoms

LAMA or LABA

(LAMA + LABA)

30

Exacerbator

2 or more per

year

Non-exacerbator

0 or 1 per year

mMRC <2 mMRC 2 or more

AFO: FEV1

< 50% pred

AFO: FEV1

> 50% pred

mMRC2 = MRC 3 Walks slower than most people on the level, stops after a

mile or so, or stops after 15 minutes walking at own pace

Triple Therapy

£35,000-£187,000

LABA

£8,000/QALY

LAMA

£7,000/QALY

Pulmonary Rehabilitation

£2,000-8,000/QALY

Stop Smoking Support with pharmacotherapy £2,000/QALY

Flu vaccination £?1,000/QALY in “at risk” population

The Value Pyramid

VBAT

• Very Brief Advice Training

• http://www.ncsct.co.uk/publication_very-brief-advice.php

http://www.ncsct.co.uk/publication_very-brief-advice.php

Triple Therapy

£35,000-£187,000

LABA

£8,000/QALY

LAMA

£7,000/QALY

Pulmonary Rehabilitation

£2,000-8,000/QALY

Stop Smoking Support with pharmacotherapy £2,000/QALY

Flu vaccination £?1,000/QALY in “at risk” population

The Value Pyramid

Pulmonary RehabilitationA structured programme combining:

• supervised exercise training (the core of PR)

• a comprehensive educational programme

• psychosocial support ATS/ERS Guidelines 2006

ACCP/ AACVPR Evidence-Based Clinical Practice Guidelines 2007

Evidence for Pulmonary Rehabilitation

Improvements in multiple outcomes of

considerable importance to the patient:

Dyspnoea

↓SOB for a given amount or intensity of activity

Exercise capacity

Health Related Quality of Life

up to 9/12 post PR

NICE Guidelines 2004,2011; ATS/ERS Guidelines 2006

Lacasse 1997, 2004; Cambach 2002; Griffiths 2003

ACCP/ AACVPR Evidence-Based Clinical Practice Guidelines 2007

Medicines Optimisation:Opportunities

• Reduce ICS burden

• Rationalising inhaled therapies and reducing cost

• Referring for PR early to defer need for higher level meds

• Joint working: local pharmacists, community teams, primary care

• Joint formularies

• Clear consistent messages

Value Pyramid

Seretide Accuhaler ®(Salmeterol & Fluticasone propionate)

Symbicort Turbohaler ®(Formoterol & Budesonide)

DuoResp Spiromax ®(Formoterol & Budesonide)

Symbicort ® – Formoterol& Budesonide))

Relvar Ellipta ®▼ – (vilanterol & Fluticasone Furoate)

Long Acting Bronchodilators and

Inhaled Corticosteroids

MDINEXThaler

AirFluSal Forspiro ®(Salmeterol & Fluticasone propionate)

Fostair ® – (Formoterol & Beclometasone)

ICS and Pneumonia

• All studies have shown an increased risk of community acquired pneumonia with high dose ICS

• Aim to keep ICS burden as low as possible

Anoro Ellipta ®▼(Vilanterol & Umeclidinium)

Duaklir Genuair ®▼(Formoterol & Aclidinium)

Ultibro Breezhaler ®▼(Indacaterol & Glycopyrronium)

Long acting bronchodilators and long acting muscarinics

Spiolto Respimat ®▼(Oldaterol/ Tiotropium)

Risk Symptoms Exacerbations

High risk, less symptoms

ICS/LABA or LAMA

High risk, more symptoms

ICS/LABA

(triple therapy)

Low risk, less symptoms

SABA or SAMA

(LABA or LAMA)

Low risk, more symptoms

LAMA or LABA

(LAMA + LABA)

42

Exacerbator

2 or more per

year

Non-exacerbator

0 or 1 per year

mMRC <2 mMRC 2 or more

AFO: FEV1

< 50% pred

AFO: FEV1

> 50% pred

mMRC2 = MRC 3 Walks slower than most people on the level, stops after a

mile or so, or stops after 15 minutes walking at own pace

Does my patient have asthma or COPD?orWhat is this Asthma COPD Overlap Syndrome? (ACOS)

• Many patients have features of asthma and COPD

• Older age group• Childhood asthma


• Main therapeutic difference is to use LAMA earlier (than if pure asthma)

• And to use lower doses of ICS (than if pure COPD)

Asthma COPD and Asthma-COPD Overlap Syndrome (ACOS) 2014 – www.ginasthma.org

wp-content/uploads/20

15/03/Drugs-and-Devices-Aprilm-

2015.pdf45

http://arns.co.uk/wp-content/uploads/2015/03/Drugs-and-Devices-Aprilm-2015.pdf

46

The correct inhaler device….

• …Is the one that the patient is able to use and will use

• There is no place for an ICS containing mdi without a spacing device

Relative lung dose, shown as maximal plasma salbutamol concentration (Cmax), from the early lung absorption

profile over the first 20 minutes following inhalation of a 1200 μg nominal dose of salbutamol.

STEPHEN J FOWLER, and BRIAN J LIPWORTH Thorax 2000;55:345

Copyright © BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.

Tips for pharmacists

• If dispensing an ICS or ICS combination always ask if patient has and is using a spacing device

• Alert if dispensing frequent SABA prescriptions (especially asthma)

• If dispensing high dose ICS flag up to GP/patient

• If you know/think the patient has asthma are you dispensing 1 device per month?

• Always ask about inhaler technique

• Consider promoting non-pharmacological treatments• SSS• PR• Self Excerise• Influenza VAc

Documents

COPD and Asthma Update