OutlineofPresentaon* ASTHMA vs. COPD

1

Current Strategies for Asthma and COPD

Talmadge E. King, Jr., M.D. Julius R. Krevans Distinguished Professorship in Internal Medicine

Chair, Department of Medicine University of California San Francisco (UCSF)

San Francisco, CA

Disclosure Statement

Dr. King has served on a Scien2fic Advisory Board for the following companies: •  InterMune •  ImmuneWorks •  Boehringer Ingelheim •  Daiichi Sankyo Pharma •  UpToDate

Outline of Presenta3on •  Asthma

– Burden of disease – Diagnosis – Management

•  COPD – Burden of disease – Diagnosis – Smoking cessa2on – Approach to Management

ASTHMA vs. COPD

2

Asthma 5

ASTHMA: Take Home Messages 1.  Asthma is chronic inFlammatory disease of the airways; leads to hyperresponsiveness to stimuli that causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning.

2.  Clinical manifestations of asthma can be controlled with appropriate treatment – there should be no more than occasional Flare-‐ups and severe exacerbations should be rare.

3.  Measurement of lung function (spirometry or peak expiratory Flow) provide an assessment of the severity of airFlow limitation, its reversibility, and its variability, and provide conFirmation of the diagnosis of asthma.

ASTHMA: Take Home Messages

4.  Medications to treat asthma can be classiFied as controllers or relievers. –  Controllers = medications taken daily on a long-‐term basis to

keep asthma under clinical control chieFly through their anti-‐inFlammatory effects.

–  Relievers = medications used on an as-‐needed basis that act quickly to reverse bronchoconstriction and relieve its symptoms.

5.  Inhaled glucorticosteroids are the most effective controller medications.

ASTHMA: Take Home Messages 6.  Rapid-‐acting inhaled beta2-‐agonist are the medications of

choice for relief of bronchoconstriction and pretreatment of exercise-‐induced bronchoconstriction.

7.  Clinical control of asthma is deFined as: –  NO (twice or less/week) daytime symptoms –  NO limitations of daily activities, including exercise –  NO nocturnal symptoms or awakening because of asthma –  NO (twice or less/week) need for reliever treatment –  Normal or near-‐normal lung function –  NO exacerbations

3

ASTHMA

•  A chronic inBlammatory disease of the airways; •  Chronic inBlammation leads to hyperresponsiveness to stimuli;

•  Variable and reversible airBlow obstruction.

Asthma •  A common chronic disease worldwide

–  ~ 300 million persons are affected worldwide.

–  ~14.9 million persons in the US –  Dramatic increases in the prevalence of atopy and asthma in Westernized countries and more recently in less-‐developed nations.

–  Responsible for about •  500,000 hospitalizations, •  5,000 deaths, and •  134 million days of restricted activity a year.

Asthma

•  Optimal management of asthma (we are better!)

–  improves quality of life – decreases the pool of those at risk for death

–  saves healthcare costs in emergency care

Diagnosis of Asthma: 3 Steps

1.  Obtain a history of episodic symptoms of airFlow obstruction

2.  Demonstrate that airBlow obstruction is at least partially reversible

3.  Exclude alternative diagnoses

4

Alternative Diagnoses •  COPD •  Vocal cord dysfunction •  CHF •  Pulmonary embolism •  Drug-‐induced cough •  Pulmonary inFiltration with eosinophilia •  Obstructive sleep apnea • Mechanical obstruction

–  e.g. benign or malignant tumor

Clues to Diagnosis • Recurrent episodes of wheezing • Troublesome cough at night • Cough or wheeze after exercise • Cough, wheeze or chest tightness after exposure to airborne dust, allergens • Colds that “go to the chest” or take more than 10 days to clear

Spirometry Establishes the Diagnosis

•  By demonstrating obstruction: –  FEV1 < 80% predicted –  FEV1/FVC < 65% predicted or below the lower limit of normal

•  By demonstrating reversibility: –  FEV1 increases >12% and at least 200 mL

Measurement of Peak Flow • When spirometry is normal but patients still have symptoms, follow up with peak Flow monitoring for 1-‐2 weeks upon arising and in the afternoon (before and after inhaled bronchodilator).

• Difference of 20% between high and low readings on same day suggests asthma.

5

Asthma Guidelines 4 Essential Components

1. Assessment & monitoring 2. Patient education 3. Control of factors contributing to asthma severity

4. Pharmacologic treatment National Asthma Education and Prevention Program: Expert panel Report 3

• Stepwise approach expanded to 6 steps with repositioned medications

• Emphasis on patient education/partnership – education at all points of care

• More attention to control of environmental factors or comorbid conditions – multifaceted approaches – consideration of SQ immunotherapy in persistent asthma

– beneFit from treating comorbid conditions

Asthma Guidelines

Assessment &

Monitoring

Asthma Care: 4 Essential

Components

1

Assessment & Monitoring •  Assess asthma severity to initiate Rx (based on current impairment)

•  Assess asthma control to monitor and adjust Rx (based on the risk of future negative events)

• Stepwise approach –  Schedule follow-‐up care –  Assess control –  Medication technique –  Written action plan –  Adherence at each visit

6

Severity vs. Control • SEVERITY = intrinsic intensity of the disease process

– Emphasized for initiating therapy • CONTROL = degree of success of treatment – Emphasized for monitoring and adjusting therapy

Eur Respir J. 2008 Sep;32:545-54

Assessment of Impairment •  Key elements of impairment:

–  Patient’s recall of symptoms –  Nighttime awakenings –  Physical activity (esp. interference with normal activity)

–  Need for rescue medications in the preceding 2 to 4 weeks (Short-‐acting beta2 agonist use)

–  Frequency and severity of exacerbations –  Quality of life –  Current pulmonary function

Assessment of Impairment

• Patient-centric, validated tools to evaluate the current asthma control include:

– Asthma Therapy Assessment Questionnaire (ATAQ)

– Asthma Control Questionnaire (ACQ)

– Asthma Control Test (ACT)

Aidan A. Long, MD: www.peerviewpress.com/d/p131

Determine Severity When Initiating Therapy

Components of Severity

INTERMITTENT PERSISTENT

Mild Moderate Severe

Symptoms <2 days/week >2 days/week Daily All day

Nighttime awakenings <2 days/month 3-4 x/month >1/week Up to 7x/ week

Short-acting beta2 agonist use

<2 days/week >2 days/week Daily Several times a day

Interference with normal activity None Minor Some Extreme

Lung Function FEV1 normal FEV1 > 80% FEV1 60-80% FEV1<60%

<2

7

Determine Severity When Initiating Therapy

Components of Severity

INTERMITTENT PERSISTENT


Symptoms <2 days/week >2 days/week Daily All day

Nighttime awakenings <2 days/month 3-4 x/month >1/week Up to 7x/ week

Short-acting beta2 agonist use

<2 days/week >2 days/week Daily Several times a day

Interference with normal activity None Minor Some Extreme

Lung Function FEV1 normal FEV1 > 80% FEV1 60-80% FEV1<60%

Assessment of Risk


ClassiBication of Asthma Severity: Based on Risk

Exacerbations requiring use of oral steroids

Intermittent Persistent


0-1/yr

>2/yr Less severe,

Longer interval

>2/yr

>2/yr More severe, shorter interval

Initial Treatment: Based on

ClassiBication of Severity

8

6 Steps of Asthma Management

Step

1



Persistent Asthma

Step

2



Persistent Asthma

Step

3

Long-acting beta agonists (LABAs)

32

•  Patient should only use a LABA at the same time as an inhaled steroid medicine.

•  Medicines that have a LABA and steroid in 1 inhaler include •  Fluticasone with salmeterol (Advair®) •  Budesonide with formoterol (Symbicort®)

•  Some LABAs come in a separate inhaler, but you must take them at the same time as a steroid medicine. •  Salmeterol (Serevent® Diskus®) •  Formoterol (Foradil® Aerolizer®).

9



Persistent Asthma

Step

4



Persistent Asthma

Step

5


Persistent Asthma

Step

6


10

Steps in ICS Dosages Low Medium High

Vanceril

84 mcg/puff 2-6 puffs 6-10 puffs > 10 puffs

Budesonide (Pulmicort ®)

200 mcg/ inhalation 1-2 inhalations 2-3 >3

Fluticasone (Flovent®)

110 mcg/puff 2 puffs 2-6 puffs > 6 puffs

Aerobid

250 mcg/puff 2-4 puffs 4-8 puffs > 8 puffs

Mometasone (Asmanex Twisthaler®)

200 mcg/inhalation

1 inhalation 2 3

Ciclesonide (Alvesco®)

Once treatment is established, the emphasis is on assessing asthma control to determine if the goals for therapy have

been met and if adjustments in therapy (step up or step down)

would be appropriate.

After Initial ClassiBication of Severity, Determine Level of Control

Control Very Poorly controlled

Not well controlled

Well Controlled

Symptoms <2 days/wk >2 days/wk All day

Nighttime

Awakenings <2/mo 1-3x/wk >4/wk

Interference with normal activity None Some Extreme

SABA use <2 days/wk >2 days/wk Several/day

FEV1 or peak Blow >80% best 60-80% best <60% best

ACT questionnaire >20 16-19 <15

The Asthma Control Test

SOB

Interference with daily activities

Nighttime awakening

SABA inhaler use

Overall rating

5

5

5

5

5

25

Worse Better

11

Adjust Treatment based on Control

Control Very Poorly controlled

Not well controlled

Well Controlled

Step

Maintain,

Consider step down if well for at least 3 months

Step up by 1 step Step up by 1-2 steps

Oral steroids?

No No Consider short course

Follow up Regular,

Q 1-6 mos

Reevaluate

In 2- 6 wks

Reevaluate

In 2 weeks

Before Step-up of Therapy

• Review adherence • Inhaler technique • Environmental control • Co-‐morbid conditions

Patient Education


Components

2

Patient Education/Partnership

• Self-management education – Teach and reinforce self-‐monitoring • signs of worsening (symptoms or peak Flow) • difference between long-‐term control and quick relief medications • correct inhaler technique • avoiding environmental triggers

– A written asthma action plan

12

Peak Flow Meters •  Establish patient’s personal best value and evaluate the response to changes in therapy.

•  Patients with moderate persistent and severe persistent asthma may beneBit from having a peak Blow meter at home and measuring their level upon arising each morning.

PEF values (personal

best, 80%, 50%)

Controller and

quick-relief medicine plan

Normal Peak Flow Varies by Gender, Age, Ethnicity

Peak Flow Meters: Caveats • Extremely wide variability even in the published predicted peak expiratory Flow reference values

• Effort dependent • Poor at detecting mild obstruction • Reference values differ for each brand of meter – normative brand-‐speciFic values currently are not available for most brands

• Helps in monitoring but not diagnosis – Particularly useful for patients without good ability to sense symptoms

13

Inhaler Technique

49

Inhaler Technique

50

Dry Powder Inhalers Environmental

Factors &

Comorbid Conditions


Components

3

14

Environmental factors and comorbid conditions

• Review exposures – advise on ways to reduce exposure – In patients with persistent asthma, consider skin allergy testing and immunotherapy

• Comorbid conditions – ABPA, GE reFlux, obesity, OSA, rhinitis & sinusitis, stress, depression, tobacco abuse

Medications


Components

4

Medications • Long-term control medications –  Inhaled Corticosteroids (ICS) –  Long acting beta agonists (LABA) – salmeterol/formoterol – last > 12 h • NOT for monotherapy / to be used with ICS (Step 3-‐4)

– Cromolyn sodium/nedocromil • Step 2 (Mild persistent) • Preventive Rx before exercise or exposure to allergens

–  Immunomodulators – omalizumab (anti-‐IgE) • Adjunctive Rx if allergies and Step 5-‐6 care (Severe persistent) • Administered where equipped to treat anaphylaxis

Steroid Treatment Tips • Inhaled corticosteroids should be used for all persistent asthma • ICS must be used with LABA (salmeterol) – due to higher than expected death rates with LABA alone

• Five day course of oral corticosteroids does not require taper • Smokers may require higher ICS doses

15

Summary • Stepwise assessment used for initial therapy and adjustment of therapy

• LABA has no role alone – only if used together with ICS

•  ICS with all persistent asthma • Patients to be partners in care – asthma control test for monitoring – written asthma action plan for assessment/Rx

Smokers are Different

•  Up to 1/3 of asthmatics smoke •  44 non-smokers and 39 light smokers with mild asthma assigned to ICS 2x day or LTA 1x day

– Even with similar FEV1, smokers had worse quality of life, more symptoms

–  ICS reduced sputum eosinophils in both –  ICS improved FEV1 only in non-‐smokers –  LTA improved AM peak Flow only in smokers

Lazarus et al. Am J Respir Crit Care Med. 2007;175:783-90

COPD 59

COPD: Take Home Messages 1.  COPD is a common condition with a high mortality. 2.  Smoking is most common risk factor. However, in many

countries, outdoor, occupational, and indoor air pollution (burning of biomass fuels) are risk factors.

3.  Clinical diagnosis considered in any patient who has dyspnea, chronic cough or sputum production, and risk factors.

4.  Spirometry is required to make diagnosis. 5.  Appropriate pharmacologic therapy can reduce COPD

symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance.

16

COPD: Take Home Messages 6.  For symptomatic patients with COPD, pulmonary rehabilitation and

maintenance of physical activity is useful to improve symptoms, exercise capacity, and quality of life.

7.  Exacerbation of COPD is an acute event characterized by worsening of respiratory symptoms that are beyond normal day-‐to-‐day variations and leads to a change in medication.

8.  Long-‐term oxygen therapy for all patients with COPD who have chronic hypoxemia.

9.  All patients should be advised to quit smoking, educated about COPD, and given a yearly inFluenza vaccination.

10.  In addition, the pneumococcal polysaccharide vaccine should be given to all patients with COPD.

COPD • A preventable and treatable disease state characterized by airFlow limitation that is not fully reversible. • AirFlow limitation – usually progressive and – associated with an abnormal inFlammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.

Celli B. R. Chest 2008;133:1451-1462

COPD • Cough or wheeze • Sputum production • Dyspnea • Chest tightness • Worsening quality of life (often without clear recognition)

Celli B. R. Chest 2008;133:1451-1462

COPD • Highly prevalent (7 to 19%; M>W; white > blacks; increases with age) • Underdiagnosed (~12M), • Undertreated, • Underperceived, and • Very costly care (~$49.9B in 2010)

17

An Accelerated Decline In Lung Function Is The Single Most Important Feature Of COPD

3rd-ranked cause of death in

the US (~100,000 each

year).

COPD: Cigarette smoking

• Most important risk factor. • Smoking leads to – an inFlammatory response, – oxidative stress, –  lung destruction, and –  interference with lung repair Smokers

Smoker, Severe COPD

Immunostaining with monoclonal antibody anti-CD45

Leukocyte Infiltration in COPD

Smoker, Mild COPD

COPD: Smoking cessation

• Slows the accelerated decline in COPD-‐related FEV1 • Reduces all-‐cause mortality rates by 27% (by reduction in CV mortality)

18

COPD • The mortality rate from COPD for women has doubled over the past 20 yrs. • Some studies suggest that women are more susceptible to the effects of tobacco smoke than men

COPD: A persistent Systemic InBlammatory state

Consultant360 12/2011

COPD: A persistent Systemic InBlammatory state

•  Associated with important systemic manifestations, especially in patients with more advanced disease. Imbalanced oxidative stress or abnormal immunologic response –  decreased fat-‐free mass –  impaired systemic muscle function –  anemia –  osteoporosis –  depression –  pulmonary hypertension, and cor pulmonale –  all of which are important determinants of outcome

Celli B. R. Chest 2008;133:1451-1462

Spirometry = COPD • Essential for diagnosis • SigniFicantly underutilized • Change in management occurs in >50% of patients with COPD when diagnosed in primary care practice

19

Who Should Get Spirometry?

Smoker/ex-‐smoker >40 yrs old who says ‘yes ’ to: • Do you cough regularly? • Do you cough up phlegm regularly? • Do even simple chores make you short of breath? • Do you wheeze when you exert yourself, or at night? • Do you get frequent colds that persist longer than those of other people you know?

Approach to Patients with COPD

Celli B. R. Chest 2008;133:1451-1462


Celli B. R. Chest 2008;133:1451-1462

BODE Index: ClassiBication of Severity

20


Celli B. R. Chest 2008;133:1451-1462

ClassiBication of Severity Severity of airflow limitation in COPD (based on postbronchodilatoe FEV1

From the Global Strategy for the Diagnosis, Management and Prevention of COPD 2013, Global Initiative for Chronic Obstructive Lung Disease (GOLD), www.goldcopd.org.

GOLD Guidelines: COPD Management

• Assess and monitor the disease • Reduce risk factors • Manage stable COPD • Manage exacerbations

COPD: a Treatable Disease

• Overall goals of treatment – to prevent further deterioration in lung function,

– improve symptoms and – quality of life, – treat complications, and – prolong a meaningful life

Celli B. R. Chest 2008;133:1451-1462

21

COPD: a Treatable Disease •  Improved survival found with:

–  Smoking cessation –  Long-‐term oxygen therapy in hypoxemic patients –  Noninvasive mechanical ventilation in some patients with acute-‐on-‐chronic respiratory failure

–  LVRS for patients with upper-‐lobe emphysema and poor exercise capacity

•  The TORCH (Towards a Revolution in COPD Health -‐-‐ > 6,000 patients) –  Combination of salmeterol and Fluticasone improved lung function and health status, AND

–  Relative risk of dying decreased by 17.5% (over the 3 years of the study). •  Pulmonary rehabilitation and lung transplantation improve symptoms and the quality of life

Celli B. R. Chest 2008;133:1451-1462

Therapeutic Options for Patients at Risk for COPD and Those With Established Disease

Celli B. R. Chest 2008;133:1451-1462

LAMA =LA muscarinic agent LVR = lung volume reduction MV = mechanical ventilation.

COPD: Importance of HyperinBlation

• Dyspnea perceived during exercise, including walking, more closely relates to the development of dynamic hyperinBlation than to changes in FEV1.

•  Improvement in exercise brought about by several therapies (bronchodilators, oxygen, lung volume reduction surgery, and even rehabilitation) is more closely related to delaying dynamic hyperinFlations than by improving the degree of airFlow obstruction.

Celli B. R. Chest 2008;133:1451-1462

Approach To COPD Exacerbations (Increased SOB, Cough, Change in Color or Volume of Sputum)

Celli B. R. Chest 2008;133:1451-1462

22


Celli B. R. Chest 2008;133:1451-1462


Celli B. R. Chest 2008;133:1451-1462

COPD: Corticosteroids •  In outpatients, exacerbations necessitate a course of systemic corticosteroids (important to wean patients quickly)

•  Standard doses of inhaled corticosteroid (ICS) aerosols, show minimal if any beneFits in the rate of decline of lung function.

•  TORCH trial = combination of ICS and LABAs was superior to ICS alone (outcomes evaluated, including survival)

•  Pneumonia (described as an adverse event but not precisely diagnosed) was more frequent in the patients receiving ICS

•  ICS should not be prescribed alone but rather in combination with an LABA.

ASTHMA: Take Home Messages 1.  Asthma is chronic inFlammatory disease of the airways; leads to hyperresponsiveness to stimuli that causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning.

2.  Clinical manifestations of asthma can be controlled with appropriate treatment – there should be no more than occasional Flare-‐ups and severe exacerbations should be rare.

3.  Measurement of lung function (spirometry of peak expiratory Flow) provide an assessment of the severity of airFlow limitation, its reversibility, and its variability, and provide conFirmation of the diagnosis of asthma.

23

ASTHMA: Take Home Messages

4.  Medications to treat asthma can be classiFied as controllers or relievers. –  Controllers = medications taken daily on a long-‐term basis to

keep asthma under clinical control chieFly through their anti-‐inFlammatory effects.

–  Relievers = medications used on an as-‐needed basis that act quickly to reverse bronchoconstriction and relieve its symptoms.

5.  Inhaled glucorticosteroids are the most effective controller medications.

COPD: Take Home Messages 1.  COPD is a common condition with a high mortality. 2.  Smoking is most common risk factor. However, in many

countries, outdoor, occupational, and indoor air pollution (burning of biomass fuels) are risk factors.

3.  Clinical diagnosis considered in any patient who has dyspnea, chronic cough or sputum production, and risk factors.

4.  Spirometry is required to make diagnosis. 5.  Appropriate pharmacologic therapy can reduce COPD

symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance.

COPD: Take Home Messages 6.  For symptomatic patients with COPD, pulmonary rehabilitation and

maintenance of physical activity is useful to improve symptoms, exercise capacity, and quality of life.

7.  Exacerbation of COPD is an acute event characterized by worsening of respiratory symptoms that are beyond normal day-‐to-‐day variations and leads to a change in medication.

8.  Long-‐term oxygen therapy for all patients with COPD who have chronic hypoxemia.

9.  All patients should be advised to quit smoking, educated about COPD, and given a yearly inFluenza vaccination.

10.  In addition, the pneumococcal polysaccharide vaccine should be given to all patients with COPD.

THANK YOU FOR YOUR ATTENTION

24

Documents

OutlineofPresentaon* ASTHMA vs. COPD