COPD Care and Treatment Guidelines - West Essex CCG

Written by Medicines Optimisation Team May 2019; Approved by MOPB May 2019; Updated in line with NICE NG115 September 2019; Review date May 2021

Offer treatment and support or refer to stop smoking

Offer pneumococcal and influenza vaccinations

Record CAT score and MRC scale and exacerbations

Offer pulmonary rehabilitation if MRC > 3

Co-develop a personalised self-management plan

Optimise treatment for comorbidities

These treatments and plans should be revisited at every review

Start inhaled therapies only if:

all the above interventions have been offered (if appropriate), and

inhaled therapies are needed to relieve breathlessness or exercise limitation

Offer SABA or SAMA to use if needed

Person still breathless or has exacerbations despite treatment?

ENSURE COPD DIAGNOSIS CONFIRMED BY SPIROMETRY (FEV1/FVC ratio <0.7)

COPD Care and Treatment Guidelines


Offer LABA + LAMA Consider LABA + ICS Choice MDI or Soft Mist DPI Choice MDI or Soft Mist DPI

1st LABA + LAMA

Spiolto® Respimat®

(Tiotropium/olodaterol

2.5/2.5mcg) (2 puffs od)

Duaklir Genuair®

(Aclidinium/formoterol

400/12mcg) (1 puff bd)

1st LABA +

ICS Fostair® (Beclomethasone/ formoterol 100/6mcg) (2 puffs bd)

Duoresp® Spiromax® (Budesonide/ formoterol 320/9mcg) (1 puff

bd)

2nd LABA + LAMA

Ultibro® Breezhaler®

(Glycopyrronium/indacaterol

85/43mcg) (1 puff od)

2nd LABA +

ICS Sereflo® (Fluticasone

propionate/salmeterol

250/25mcg) (2 puffs bd)

AirFluSal Forspiro® (Fluticasone propionate/salmeterol 500/50mcg ) (1 puff bd) Relvar® Ellipta® (Fluticasone furoate /vilanterol 92/22mcg)

(1 puff od)

Consider 3 month trial of LAMA + LABA + ICS and only continue if improvement Discuss with patient the risk of developing pneumonia before prescribing ICS. It may not be advisable for patients whose admission to hospital was due to pneumonia.

MDI DPI Trimbow® (Beclometasone/ formoterol/ glycopyrronium) (2 puffs bd) Trelegy® (Fluticasone/umeclidinium/vilanterol) (1 puff od at the same time each day)

CHECK INHALER TECHNIQUE AND OPTIMISE NON-PHARMACOLOGICAL INTERVENTIONS.

No asthmatic features/features suggesting steroid responsiveness*

Asthmatic features/features suggesting steroid responsiveness*

Person still has symptoms that interfere with activities of daily living or has severe exacerbations (requiring hospitalisation) or has 2 moderate exacerbations within the last year treatment?

*Asthmatic features/features suggesting steroid responsiveness in this context include any previous secure diagnosis of asthma or atopy, a higher blood eosinophil count (>300 cells/ml (0.3*10⁹/l), substantial

variation in FEV1 over time (at least 400ml) or substantial diurnal variation in peak expiatory flow (at least 20%)

Person still has symptoms that interfere with activities of daily living or has exacerbations. Consider referring to specialist.

For guidance on ICS therapy and withdrawal please see link https://www.pcrs-uk.org/sites/pcrs-uk.org/files/SteppingDownICS_FINAL5.pdf

https://www.pcrs-uk.org/sites/pcrs-uk.org/files/SteppingDownICS_FINAL5.pdf


HIGH IMPACT INTERVENTION 7 – OPTIMISE DRUGS AND DEVICES

Most people with COPD – whatever their age – can develop adequate inhaler technique if they are given training.

However, people with significant cognitive impairment may be unable to use any form of inhaler device. In most

people with COPD, however, a pragmatic approach guided by individual patient assessment is needed when

choosing a device.

In most cases bronchodilator therapy is best administered using a hand-held inhaler (including a spacer if appropriate)

Provide an alternative inhaler if a person cannot use a particular one correctly or it is not suitable for them

do so

NO YES Assess the person’s ability to use an inhaler regularly and correct it if necessary. This should be done by a healthcare professional competent to do so. Refer to Right Breath website: www.rightbreathe.com for additional inhaler prescribing Information The website www.rightbreathe.com also has the information regarding which spacers are compatible with different MDIs. You can also get phone apps to support correct use of inhalers: RightBreathe App and MyCOPD App

Key Messages:

- Inhalers should be prescribed by brand name to ensure patients receive the correct device, with which their inhaler technique has been assessed and they are able to use

- Inhaler technique should be assessed prior to prescribing inhalers in patients who have never used inhaled medication before

- Check inhaler technique at every opportunity / encounter with the patient and before considering dose escalation

- Whenever possible, prescribe patients the same inhaler device for each drug class

Inhaler Technique Assessment

- The In-Check DIAL inspiratory flow meter should be used to check inspiratory flow. - Depending on the patient and the drug classes required (e.g. SABA, LAMA, LABA, LAMA/LABA, ICS/LABA etc.);

check the patient’s inspiratory flow through a range of different devices. It is useful to check inspiratory flow two or three times through each device to ensure that the patient achieves the same inspiratory flows consistently.

- Teach correct inhaler technique: education on correct inhaler technique requires the healthcare professional to demonstrate correct inhaler technique to the patient

- Check inhaler technique and check understanding

If first line recommendation is NOT suitable (for reasons such as lack of dexterity, side

effects etc.) which device would be most suitable for my patient?

Does my patient have enough inspiratory effort/volume to inhale the contents of a dry

powder inhaler? (Can my patients achieve an optimal peak inspiratory flow rate of at

least 60 L/min?)

Consider a soft mist inhaler or a metered dose

inhaler (MDI) with a spacer. *MDI with/without

spacer and the Respimat device do not require

inspiratory effort – but does require co-ordination to

ensure sufficient inhalation of dose. The Respimat

device cannot be used with a spacer device.

Try placebos or use an In-Check dial if available before initiating inhalers. Check inhaler technique at every opportunity.

Use Dry powder inhalers (DPIs) ** Twice daily administration is preferred to optimise bronchodilation over a 24 hour period. Duration of action of once daily preparations varies from 18 to 24 hours.

Only prescribe inhalers after people have been trained to

use them and can demonstrate satisfactory technique

http://www.rightbreathe.com/


- Once the patient has been taught and shown how to use their inhaler, they should be asked to demonstrate how they would use it. This allows the healthcare professional to check they understand how to use their inhaler device, and to reinforce any steps they are unable to perform correctly.

- Educate patient on rationale for using inhaled medication. Adherence to prescribed inhaled medication may be improved if the rationale for using each medicine is explained to the patient. This should also include when and how to use their inhaler device

Use and maintenance of Spacers - Provide a spacer compatible with the person's metered-dose inhaler - Advise people to use a spacer with a metered-dose inhaler in the following way:

o administer the drug by single actuations of the metered-dose inhaler into the spacer, inhaling after each actuation

o there should be minimal delay between inhaler actuation and inhalation o normal tidal breathing can be used as it is as effective as single breaths o repeat if a second dose is required

- Advise people on spacer cleaning. Tell them: o not to clean the spacer more than monthly

o hand wash using warm water and washing‑up liquid, and allow spacer to air dry

Nebulisers Think about nebuliser therapy for people with distressing or disabling breathlessness despite maximal therapy using inhalers. Do not prescribe nebulised therapy without an assessment of the person's and/or carer's ability to use it. Consider non-pharmacological option:

Pulmonary Rehabilitation Do not continue nebulised therapy without assessing and confirming that 1 or more of the following occurs:

a reduction in symptoms

an increase in the ability to undertake activities of daily living

an increase in exercise capacity

an improvement in lung function Identifying and managing anxiety and depression in people with COPD Consider whether people have anxiety or depression, particularly if they:

have severe breathlessness

are hypoxic

have been seen at or admitted to a hospital with an exacerbation of COPD

Consider referral to Health Minds https://www.hpft.nhs.uk/services/community-services/healthy-minds-west-essex-

iapt/.

Oxygen Therapy – Specialist initiation only

Be aware that inappropriate oxygen therapy in people with COPD may cause respiratory depression.

Do not offer ambulatory or short-burst oxygen therapy to manage breathlessness in people with COPD who have

mild or no hypoxaemia at rest. Seek advice from EPUT Respiratory Team if required.

https://www.hpft.nhs.uk/services/community-services/healthy-minds-west-essex-iapt/

https://www.hpft.nhs.uk/services/community-services/healthy-minds-west-essex-iapt/


MEDICINES OPTIMISATION SAFETY ISSUES

Tiotropium: risk of cardiovascular side effects - MHRA: Drug Safety Update 2015; 8 (7): 1

When using tiotropium delivered via Respimat or Handihaler to treat chronic obstructive pulmonary disease (COPD):

take the risk of cardiovascular side effects into account for patients with conditions that may be affected by the

anticholinergic action of tiotropium, including:

myocardial infarction in the last 6 months

unstable or life threatening cardiac arrhythmia

cardiac arrhythmia requiring intervention or a change in drug therapy in the past year

hospitalisation for heart failure (NYHA Class III or IV) within the past year

Tell these patients to report any worsening of cardiac symptoms after starting tiotropium. Regularly review treatment of patients at high risk of cardiovascular events Remind patients not to exceed the recommended once daily dose Continue to report suspected side effects to tiotropium or any other medicine on a Yellow Card: www.gov.uk/yellowcard Inhaled corticosteroids for COPD - Discuss the risk of side effects (including pneumonia)

1. Risk of pneumonia Physicians should remain vigilant for pneumonia and other infections of the lower respiratory tract (i.e., bronchitis) in patients with chronic obstructive pulmonary disease who are treated with inhaled products that contain steroids MHRA: Drug Safety Update 2007; 1(3): 5 and 2010; 4(2): A4 Available from www.gov.uk/drug-safety-update/inhaled-corticosteroids-pneumonia and www.gov.uk/drug-safety-update/inhaled-and-intranasal-corticosteroids.

2. Risk of psychological and behavioural side effects A review of data for inhaled and intranasal corticosteroids suggests that in addition to the known systemic effects of these medicines, a range of psychological or behavioural effects may also occur. These include:

psychomotor hyperactivity

sleep disorders

anxiety

depression

aggression (particularly in children).

Oral corticosteroids Long-term use of oral corticosteroid therapy in COPD is not normally recommended Some people with advanced COPD may need long-term oral corticosteroids when these cannot be withdrawn following an exacerbation. In these cases, the dose of oral corticosteroids should be kept as low as possible Monitor people who are having long-term oral corticosteroid therapy for osteoporosis, and give them appropriate prophylaxis. Start osteoporosis prophylaxis without monitoring for people over 65 years of age Fluoroquinolone antibiotics Fluoroquinolones are associated with prolonged, serious, disabling and potentially irreversible drug reactions including tendonitis, tendon rupture, arthralgia, pain in extremities, gait disturbance, neuropathies associated with paraesthesia, depression, fatigue, memory impairment, sleep disorders, and impaired hearing, vision, taste and smell. Indications for fluoroquinolones will be restricted. In addition, fluoroquinolones should generally be: avoided in people who have previously had serious side effects with a fluoroquinolone or quinolone antibiotic used with special caution in people over 60 years, people with kidney disease and those who have had an organ transplantation Concomitant treatment with a fluoroquinolone and a corticosteroid should be avoided

http://www.gov.uk/yellowcard

http://www.gov.uk/drug-safety-update/inhaled-corticosteroids-pneumonia

http://www.gov.uk/drug-safety-update/inhaled-and-intranasal-corticosteroids

http://www.gov.uk/drug-safety-update/inhaled-and-intranasal-corticosteroids


Oral prophylactic antibiotic therapy • Before starting prophylactic antibiotic therapy in a person with COPD, think about whether respiratory

specialist input is needed • Consider azithromycin (usually 250 mg 3 times a week) [off label] for people with COPD if they:

o do not smoke and o have optimised non-pharmacological management and inhaled therapies, relevant vaccinations and

(if appropriate) have been referred for pulmonary rehabilitation and o continue to have 1 or more of the following, particularly if they have significant daily sputum

production: – frequent (typically 4 or more per year) exacerbations with sputum production – prolonged exacerbations with sputum production – exacerbations resulting in hospitalisation

Before offering prophylactic antibiotics, ensure that the person has had:

sputum culture and sensitivity (including tuberculosis culture), to identify other possible causes of persistent

or recurrent infection

training in airway clearance techniques to optimise sputum clearance (see guideline)

CT scan of the thorax to rule out other lung pathologies

Before starting azithromycin, ensure the person has had:

an electrocardiogram (ECG) to rule out prolonged QT interval and

baseline liver function tests

Advise people about the small risk of hearing loss and tinnitus, and tell them to contact a healthcare professional if

this occurs.

Review prophylactic azithromycin after the first 3 months, and then at least every 6 months

Only continue treatment if the continued benefits outweigh the risks

Be aware that there are no long-term studies on the use of prophylactic antibiotics in people with COPD.

For people who are taking prophylactic azithromycin and are still at risk of exacerbations, provide a non-macrolide

antibiotic to keep at home as part of their exacerbation action plan.

Be aware that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD.

Prophylactic antibiotics reduce the risk of around half of people having an exacerbation and the number of

exacerbations per year in people with COPD and sputum production.

Other oral therapies

Oral theophylline should only be used after a trial of short- and long-acting bronchodilators, or for people who are unable to use inhaled therapy

Oral mucolytic therapy o Consider for people with a chronic cough productive of sputum o Only continue mucolytic therapy if there is symptomatic improvement o Do not routinely use mucolytic drugs to prevent exacerbations

Oral anti-oxidant therapy - Treatment with alpha-tocopherol and beta-carotene supplements, alone or in combination, is not recommended

Oral anti-tussive therapy -Should not be used


HIGH IMPACT INTERVENTION 8 – SELF-MANAGEMENT

Increased breathlessness is usually managed by taking increased doses of short-acting bronchodilators Consider oral corticosteroids for people in the community who have an exacerbation with a significant increase in breathlessness that interferes with daily activities Remember to code (e.g. as acute exacerbation of COPD) to help with GOLD classification Prescribe prednisolone 30 mg orally for 5 days (NICE NG155 update July 2019) Develop an individualised exacerbation action plan in collaboration with each person with COPD who is at risk of exacerbations. Offer people a short course of oral corticosteroids and a short course of oral antibiotics to keep at home as part of their exacerbation action plan if:

they have had an exacerbation within the last year, and remain at risk of exacerbations

they understand and are confident about when and how to take these medicines, and the associated benefits and harms

they know to tell their healthcare professional when they have used the medicines, and to ask for replacements.

Encourage people with COPD to respond promptly to exacerbation symptoms by following their action plan, which may include:

adjusting their short-acting bronchodilator therapy to treat their symptoms

taking a short course of oral corticosteroids if their increased breathlessness interferes with activities of daily living

adding oral antibiotics if their sputum changes colour and increases in volume or thickness beyond their normal day-to-day variation

telling their healthcare professional At all review appointments, discuss corticosteroid and antibiotic use with people who keep these medicines at home For people who have used 3 or more courses of oral corticosteroids and/or oral antibiotics in the last year, investigate the possible reasons for this Be aware that: An acute exacerbation of COPD is a sustained worsening of symptoms from a person's stable state A range of factors (including viral infections and smoking) can trigger an exacerbation Many exacerbations (including some severe exacerbations) are not caused by bacterial infections so will not respond to antibiotics Consider an antibiotic for people with an acute exacerbation of COPD, but only after taking into account:

the severity of symptoms, particularly sputum colour changes and increases in volume or thickness beyond the person's normal day-to-day variation

whether they may need to go into hospital for treatment (see the NICE guideline on COPD, NG115)

previous exacerbation and hospital admission history, and the risk of developing complications

previous sputum culture and susceptibility results

the risk of antimicrobial resistance with repeated courses of antibiotics For guidance see next page (https://www.nice.org.uk/guidance/ng114/resources/guide-to-resources-pdf-6602624893) If an antibiotic is given, give advice:

about possible adverse effects of the antibiotic, particularly diarrhoea

that symptoms may not be fully resolved when the antibiotic course has been completed If no antibiotic is given, give advice about an antibiotic not being needed currently In both situations, give advice about seeking medical help if:

symptoms (such as sputum colour changes and increases in volume or thickness) worsen rapidly or significantly or

symptoms do not start to improve within 2 to 3 days (or other agreed time) or

the person becomes systemically very unwell

https://www.nice.org.uk/guidance/ng115

https://www.nice.org.uk/guidance/ng114/resources/guide-to-resources-pdf-6602624893



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COPD Care and Treatment Guidelines - West Essex CCG