Gerichte therapie bij Astma COPD overlap syndroom .3 Achtergrond • Asthma vs. COPD Asthma COPD

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Text of Gerichte therapie bij Astma COPD overlap syndroom .3 Achtergrond • Asthma vs. COPD Asthma COPD

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    Dr. Tobias Bonten

    AIOS Huisartsgeneeskunde, Postdoc en Epidemioloog

    Longziekten en Public Health & Eerstelijns Geneeskunde

    LEIDS UNIVERSITAIR MEDISCH CENTRUM

    Gerichte therapie bij Astma COPD overlap syndroom

    (potentiële) belangenverstrengeling Geen

    Disclosure belangen spreker

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    GERICHTE BEHANDELING

    9-Feb-173

    Achtergrond

    • Astma vs. COPD

    9-Feb-174

    Astma COPD

    Risico factor Atopie (allergie) Roken / lucht verontreiniging

    Leeftijd Alle (meestal begin 40

    Symptomen

    Hoesten Ja Ja

    Slijm Niet vaak Vaak

    Adem geluiden Piepen Piepen, gereutel

    Kortademigheid Wisselend Persisterend (exacerbaties)

    Prognosis Stabiel, normale levensverwachting

    Progressief, verminderde levensverwachting

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    Achtergrond

    • Asthma vs. COPD

    Asthma COPD

    Diagnose

    Laboratorium Allergie (IgE, eosinophielen)

    Geen

    Pulmonary function Normaal of reversibele obstructie

    Irreversibele obstructie

    Achtergrond

    • Astma EN COPD?  Astma COPD overlap syndroom (ACOS)

    ?

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    ACOS ?

    2. Australian Asthma management Handbook Pooling of features corresponding to asthma and COPD, followed by a trial of Inhalation Corticosteroids

    1. GINA/GOLD (guideline) List 9 features: similar number of asthma and COPD features  ACOS more likely; spirometry recommended

    3. Japanese Respiratory Society COPD guidelines Asthma component: paroxysmal dyspnoea, cough and wheeze worse at night and early morning, atopy, sputum/blood eosinophilia.

    4. Spanish COPD consensus document - Major criteria:

    - Increase FEV1 ≥ 15% and ≥400ml - Eosinophilia - History of asthma

    - Minor criteria: - Total IgE - Atopy - ≥2 ocassions: FEV1 ≥ 12% and ≥200ml

     ACOS if  2 major  1 major + 2 minor

    5. Czech Pneumological and Physiological Society - Major criteria:

    - Increase FEV1 ≥ 15% and ≥400ml - Positive provocation test - FeNO ≥ 45-50 ppb and/or sputum eosinophils ≥3% - History of asthma

    - Minor criteria: - FEV1 ≥ 12% and ≥200ml - Total IgE - Atopy and COPD diagnosis

     ACOS if  2 major  1 major + 2 minor

    Gibson PG, et al. Thorax 2015

    ACOS fenotypen…?

    Bateman, Lancet Respir Med 2015

    CHAOS instead of ACOS?

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    Overzicht

    1. Is ACOS klinisch relevant?

    2. Hoe vaak komt ACOS voor?

    3. Identificeren van ACOS in de eerste lijn

    4. Adviezen over behandeling van ACOS

    9-Feb-179 Insert > Header & footer

    Overzicht

    1. Is ACOS klinisch relevant?

    2. Hoe vaak komt ACOS voor?

    3. Identificeren van ACOS in de eerste lijn

    4. Adviezen over behandeling van ACOS

    9-Feb-1710 Insert > Header & footer

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    ACOS – klinisch relevant?

    Nielsen M, et al. Int J COPD 2015

    Frequency of exacerbations among ACOS patients is higher than in Asthma or COPD

    ACOS – klinisch relevant? Eigen onderzoek bij 864 patienten met Astma/COPD

    1. COPD AND Asthma in registry

    2. COPD AND Asthma in registry OR ACOS as text in EMR

    3. Self-reported COPD AND Asthma

    4. FEV1/FVC < 0.7 AND ≥10 pack-years AND asthma

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    ACOS – klinisch relevant?

    • 864 patiënten met Astma/COPD

    • Follow-up 1.8jr

    • Exacerbatie: voorschrift corticosteroid of antibioticum door huisarts

    * adjusted for: age, sex, bmi, current smoking, FEV1/FVC ratio at baseline, ICS use, number of exacerbations in previous year

    ACOS – klinisch relevant?

    * adjusted for: age, sex, bmi, current smoking, FEV1/FVC ratio at baseline, ICS use, number of exacerbations in previous year

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    Survival is worse among ACOS patients than in Asthma or COPD, depending on age of asthma onset

    Lange P, Lancet Resp Med 2016

    ACOS – klinisch relevant?

    ACOS – relevant for society?

    Gerhardsson de Verdier M, Val Health 2015

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    Overzicht

    1. Is ACOS klinisch relevant?

    2. Hoe vaak komt ACOS voor?

    3. Identificeren van ACOS in de eerste lijn

    4. Adviezen over behandeling van ACOS

    9-Feb-1717 Insert > Header & footer

    Eerdere studies Karakteristieken en ACOS prevalentie

    Study Population Age Prevalence (%) Definition

    Brzostek Smoking >45 100 Doctor diagnosed asthma + COPD

    Fu Asthma, COPD, ACOS

    >55 55.5 Symptoms, flow variability, incomplete reversible obstruction

    Lee Asthma, ACOS 41-79 37.9 Asthma with incomplete reversible obstruction

    Milanese Asthma ≥65 28.8 Asthma and chronic bronchitis and/or impaired diffusion

    Miravitles COPD, ACOS 40-80 17.7 COPD (FEV1/FVC

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    Eerdere studies Karakteristieken en ACOS prevalentie

    Study Population Age Prevalence (%) Definition

    Brzostek Smoking >45 100 Doctor diagnosed asthma + COPD

    Fu Asthma, COPD, ACOS

    >55 55.5 Symptoms, flow variability, incomplete reversible obstruction

    Lee Asthma, ACOS 41-79 37.9 Asthma with incomplete reversible obstruction

    Milanese Asthma ≥65 28.8 Asthma and chronic bronchitis and/or impaired diffusion

    Miravitles COPD, ACOS 40-80 17.7 COPD (FEV1/FVC

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    Overzicht

    1. Is ACOS klinisch relevant?

    2. Hoe vaak komt ACOS voor?

    3. Identificeren van ACOS in de eerste lijn

    4. Adviezen over behandeling van ACOS

    9-Feb-1721 Insert > Header & footer

    ACOS ?

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    Simpeler oplossing? Bij patiënten met COPD

    ACOS 1: Spaanse consensus criteria

    versus

    ACOS 2: Alleen astma < 40 jaar, diagnosed only on the basis of a history of

    asthma before the age of 40 years

    Barrecheguren, Int J COPD 2015

    Prevalentie

    Barrecheguren, Int J COPD 2015

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    Conclusie Simpeler oplossing voor eerste lijn?

    Patients diagnosed with ACOS in COPD on the basis of a previous diagnosis of

    asthma before the age of 40 years are very similar to patients diagnosed with

    ACOS by the more restrictive criteria proposed by the Spanish consensus.

    Therefore, the previous diagnosis of asthma before 40 years of age in a patient

    with COPD can be used as a presumptive diagnosis of ACOS.

    Barrecheguren, Int J COPD 2015

    Overzicht

    1. Is ACOS klinisch relevant?

    2. Hoe vaak komt ACOS voor?

    3. Identificeren van ACOS in de eerste lijn

    4. Adviezen over behandeling van ACOS

    9-Feb-1726 Insert > Header & footer

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    ACOS – relevant voor behandeling? Timing van ICS

    9-Feb-1727

    STEP 1 STEP 2 STEP 3

    STEP 4

    STEP 5

    Low dose ICS

    Consider low

    dose ICS Leukotriene receptor antagonists (LTRA)

    Low dose theophylline*

    Med/high dose ICS

    Low dose ICS+LTRA

    (or + theoph*)

    As-needed short-acting beta2-agonist (SABA)

    Low dose

    ICS/LABA*

    Med/high

    ICS/LABA

    Refer for add-on

    treatment e.g.

    anti-IgE

    Add tiotropium#

    High dose ICS

    + LTRA

    (or + theoph*)

    Add tiotropium# Add low dose OCS

    As-needed SABA or low dose ICS/formoterol**

    COPD: ICS= step 3

    Asthma: ICS= step 1-2

    GINA-GOLD

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    GINA-GOLD: treatment ACOS

    Initial treatment:

    - Patients with features of asthma: receive adequate controller

    therapy including inhaled corticosteroids, but not long-acting

    bronchodilators alone (as monotherapy)

    - Patients with features of COPD: receive appropriate

    symptomatic treatment with bronchodilators or combination

    therapy, but not inhaled corticosteroids alone (as

    monotherapy).

    www.ginaasthma.org

    Hoe behandelen NL huisartsen patiënten met ACOS?

    9-Feb-1730

    Bonten TN et al: Defining Asthma COPD overlap syndrome: a population based study. ERJ 2017, accepted for publication

    1 2 3 4 5 6

    Characteristic COPD in registry +

    Asthma in registry

    COPD in registry +

    Asthma in registry

    OR

    ACOS as text in electronic record

    COPD self-reported

    + Asthma

    self-reported

    FEV1/FVC < 0.7 +

    ≥10 pack-years +

    asthma

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    Take home messages

    1. Is ACOS klinisch relevant? Hogere kans op exacerbaties dan

    astma patiënten, hogere mortaliteit

    2. Hoe vaak komt ACOS voor? ± 10% in 1e lijns astma/COPD

    populatie

    3. Identificeren van ACOS in de eerste lijn: voorgeschiedenis van

    astma/symptomen bij COPD’er, bij hoge ziektelast verwijzen

    naar longarts voor diagnostiek

    4. Adviezen over behandeling van ACOS: ICS afhankelijk van

    klachtenpatroon. Eenmalige verwijzing naar longarts voor

    diagnostiek en behandeladvies?

    9-Feb-1731

    Dankwoord Leiden University Medical Center study team

    9-Feb-1732 Insert > Header & footer

    Prof. Niels Chavannes

    Prof. Christian Taube

    Dr. Marise Kasteleyn

    Prof. Pieter Hiemstra

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    Evt. extra slides

    9-Feb-1733 Insert > Header & footer