COPD? Where Are We Headed? Dr. NAGHMAN BASHIR FCPS, MRCP(UK) Consultant Physician naghman@gmail.com

Clinical Phenotypes Macrolides to prevent Exacerbations Role of Statins in COPD Tobacco Cessation Tools

Clinical Phenotypes Macrolides to prevent Exacerbations Role of Statins in COPD Tobacco Cessation Tools

(C) (D) (B) (A) Risk ≥ 2 or > 1 leading to hospital admission (GOLD Classification of Airflow Limitation)) Risk (Exacerbation history) ≥ 2 or > 1 leading to hospital admission 1 (not leading to hospital admission) Symptoms (C) (D) (A) (B) CAT < 10 4 3 2 1 CAT > 10 Breathlessness mMRC 0–1 mMRC > 2

CLINICAL PHENOTYPES ”…those attributes of the disease alone or in combination that describe the differences between individuals with COPD in relation to parameters that have clinical significance (symptoms, exacerbations, response to treatment, rate of progression disease, or death). Am J Respir Crit Care Med 2010; 182: 598-604 …identify patients with different response to the treatments available and allow a more personalized approach to treatment…

RELEVANT PHENOTYPES A) Infrequent exacerbator, with either chronic bronchitis or emphysema; B) Overlap COPD-asthma; C) Frequent exacerbator with predominant emphysema; D) Frequent exacerbator with predominant chronic bronchitis Pharmacological treatment of stable COPD. Arch Bronconeumol 2012; 48: 247-257

Infrequent exacerbator, with either chronic bronchitis or emphysema Any patient experiencing less than two exacerbations per year Currently no anti-inflammatory treatment indicated or licensed for infrequent exacerbators, Long-acting bronchodilators, alone or in combination, and the possible addition of theophyllines in the more severe cases

Overlap COPD-Asthma History of previous asthma before the age of 40, The demonstration of eosinophilic inflammation in sputum or increased peripheral eosinophilia, Enhanced reversibility in airflow obstruction after the bronchodilator test. Inhaled corticosteroids together with long-acting bronchodilators irrespective of the severity of the airflow obstruction

Frequent exacerbator with predominant chronic bronchitis Inflammation, Hypersecretion, Increased risk of Bacterial colonization and infections Bronchodilators, inhaled corticosteroids, and respond to treatment with the PDE4 inhibitor roflumilast. During exacerbations long-term treatment with macrolides , quinolones, and mucolytics.

Frequent exacerbator with predominant emphysema Present NOT with chronic cough and sputum production but with typical clinical and radiological signs of emphysema Longacting bronchodilators and, in some cases, inhaled corticosteroids.

Bacterial Viral Eosinophilic Pauci Inflammatory PHENOTYPES Bacterial Viral Eosinophilic Pauci Inflammatory

Fast Decliner Inflammatory Systemic Pulmonary Hypertension-COPD OTHER PHENOTYPES Fast Decliner Inflammatory Systemic Pulmonary Hypertension-COPD

Clinical Phenotypes Macrolides to prevent Exacerbations Role of Statins in COPD Tobacco Cessation Tools

ERYTHROCIN Author (Year) Number Results Suzuki (Chest 2001) 109 Reduced number of exacerbations and common colds Yamaya (J AM Ger Soc 2008) 123 Reduced number of exacerbations and hospitalisation Seemungal (AJRCCM 2008) Reduction in the frequency of exacerbations Shorter duration of exacerbation Longer time to the first exacerbation He (Resp. 2010) 36 Reduction in the exacerbation rate Delay in the time to the first exacerbation

CLARITHROCIN Author (Year) Number Results Banerjee (Treat Res Med 2004) 67 No difference in the frequency of exacerbations Yamaya (J AM Ger Soc 2008) 123 Reduced number of exacerbations and hospitalisation

AZITHROCIN Author (Year) Number Results Blasi (Pulm Pharm Ther, 2010) 22 Reduction in the number of exacerbations Reduction in the number of hospitalisations Improvement in quality of life Albert (NEJM 2011) 1142 Reduction in the frequency of exacerbations Longer time to first exacerbation Improvement in quality of food

Clinical Phenotypes Macrolides to prevent Exacerbations Role of Statins in COPD Tobacco Cessation Tools

Clinical Phenotypes Macrolides to prevent Exacerbations Role of Statins in COPD Tobacco Cessation Tools

The TOOL E CIAGARETTES People smoke for nicotine but die from tar and smoke

Combustible Tobacco …upto 98% of tobacco-related deaths are attributable to combustible products… ..Increasing interest in HARM REDUCTION and CHRONIC CARE APPROACHES……. NEJM 370; 4: 297-299 (JAN 23, 2014)

E Cigarettes On Line Survey 91% had attempted to quit. Complete replacement (79%), partial replacement (17%) Improvement in general health (91%), smokers cough (97%) Ability to exercise (83%) Sense of smell (80%), and taste (73%) E cigarettes as potential harm reduction product. Nov 2009. tobaccoharmreduction.org/wpapers/011.htm

Lancet 2013; 382:1629-37 E cigarettes, with or without nicotine, were modestly effective at helping smokers to quit with similar achievement of of abstinence as with nicotine patches, and with fewer side effects.

THE MILLION DOLLAR QUESTION Will e cigarettes cause more or fewer people to smoke/quit?

Thank You Merci Grazie Gracias Danke