Chronic Obstructive Pulmonary Disease World COPD Day Chronic Obstructive Pulmonary Disease Press Conference Kyoto, Japan November 19, 2006

World COPD Day Press Conference Opening Remarks Yoshinosuke Fukuchi, MD, PhD Introduction of GOLD Sonia Buist, MD New GOLD Guidelines Suzanne Hurd, PhD Klaus F. Rabe, MD, PhD Additional Comments Peter Calverley, MD Comments from WONCA Chris van Weel, MD Closing Remarks Claude Lenfant, MD World COPD Day Press Conference

Definition of COPD Chronic Obstructive Pulmonary Disease is a preventable and treatable disease with some significant extrapulmonary effects. The pulmonary component is characterized by airflow limitation that is not fully reversible. Healthy Alveolus COPD

Chronic Obstructive Pulmonary Disease (COPD) The airflow limitation in COPD is usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles and gases Severe COPD leads to respiratory failure, hospitalization and eventually death from suffocation

Aging Populations Risk Factors for COPD Nutrition Infections Socio-economic status Aging Populations

Dr. A. Sonia Buist Introduction of GOLD Chair, GOLD Executive Committee Portland, Oregon USA

G O L D lobal Initiative for Chronic bstructive ung isease November 19, 2006 World COPD Day, Kyoto Japan

Why was GOLD Started? The social and economic burden of COPD is increasing rapidly in countries at all levels of economic development COPD is under-appreciated, under-diagnosed and under-treated Important questions about COPD are still unanswered

COPD is Under-appreciated and Under-diagnosed Example from Japan: NICE Survey of COPD prevalence Carried out in several regions of Japan using standardized methods

COPD Prevalence Rate (adjusted)* in Population  40 years 8.5%** 0.3% Study MHW Survey 5.3 vs 0.2M COPD patients in Japan ≥40 years *Adjusted for age, sex, cluster **8.5-10.9% depending on criteria Fukuchi et al. Respirology 2004;9:458-65

COPD Prevalence Survey (NICE) in Japan Had prior diagnosis Did not have prior diagnosis: Fukuchi et al. Respirology 2004;9:458-65

Prevalence of GOLD Stage 1+ COPD1, Guangzhou, China MEN 15.3% WOMEN 7.6% 1 FEV1/FVC<0.70, post BD

Of the six leading causes of death in the United States, only COPD has been increasing steadily since 1970. Source: Jemal A. et al. JAMA 2005

COPD Mortality by Gender, U.S., 1980-2000 Number Deaths x 1000

COPD Mortality Worldwide 1990 2020 Ischaemic heart disease Cerebrovascular disease Lower resp infection Diarrhoeal disease Perinatal disorders COPD Tuberculosis Measles Road Traffic Accidents Lung Cancer 3rd 6th Stomach Cancer HIV Suicide Source: Murray & Lopez. Lancet 1997

Why is COPD Increasing Worldwide? Increase in exposure to risk factors (especially tobacco) in developing countries & in women Changing demographics globally with more of the population, especially in the developing countries living into the COPD age range

Dr. Suzanne S. Hurd New GOLD Guidelines GOLD Scientific Director Gaithersburg, Maryland, USA

GOLD Objectives Increase awareness of COPD among health professionals, health authorities, and the general public Improve diagnosis, management and prevention of COPD Stimulate research in COPD

Global Strategy for Diagnosis, Management and Prevention of COPD Definition, Classification Burden of COPD Risk factors Pathogenesis, pathology, pathophysiology Management Practical Considerations Revised 2006

Global Strategy for Diagnosis, Management and Prevention of COPD Revised 2006 MAJOR CHANGES Global Strategy for Diagnosis, Management and Prevention of COPD Revised 2006

Dr. Klaus Rabe New GOLD Guidelines Chair, GOLD Science Committee Leiden, The Netherlands

Global Strategy for Diagnosis, Management and Prevention of COPD Definition, Classification Burden of COPD Risk factors Pathogenesis, pathology, pathophysiology Management Practical Considerations Revised 2006

Definition of COPD Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. Its pulmonary component is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.

indoor/outdoor pollution Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS cough tobacco A diagnosis of COPD should be considered in any patient who has cough, sputum production, or dyspnea and/or a history of exposure to risk factors. The diagnosis is confirmed by spirometry. To help identify individuals earlier in the course of disease, spirometry should be performed for patients who have chronic cough and sputum production even if they do not have dyspnea. Spirometry is the best way to diagnose COPD and to monitor its progression and health care workers to care for COPD patients should have assess to spirometry. sputum occupation shortness of breath indoor/outdoor pollution è SPIROMETRY

Spirometry for COPD Diagnosis and Classification of Severity

Classification of COPD Severity by Spirometry Stage I: Mild FEV1/FVC < 0.70 FEV1 > 80% predicted Stage II: Moderate FEV1/FVC < 0.70 50% < FEV1 < 80% predicted Stage III: Severe FEV1/FVC < 0.70 30% < FEV1 < 50% predicted Stage IV: Very Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

COPD and Co-Morbidities COPD has significant extrapulmonary (systemic) effects Weight loss, nutritional abnormalities Skeletal muscle dysfunction

COPD and Co-Morbidities COPD patients are at increased risk: Myocardial infarction, angina Osteoporosis Respiratory infection Depression Diabetes COPD and lung cancer

Dr. Peter Calverley New GOLD Guidelines GOLD Executive/Science Committee Liverpool, England

Global Strategy for Diagnosis, Management and Prevention of COPD Definition, Classification Burden of COPD Risk factors Pathogenesis, pathology, pathophysiology Management Practical Considerations Revised 2006

Four Components of Care Assess and Monitor Disease Reduce Risk Factors Manage Stable COPD Manage Exacerbations

GOALS of COPD MANAGEMENT VARYING EMPHASIS WITH DIFFERING SEVERITY Relieve symptoms Prevent disease progression • Improve exercise tolerance • Improve health status • Prevent and treat complications • Prevent and treat exacerbations • Reduce mortality

DIAGNOSIS AND RISK FACTORS Bronchodilator testing no longer mandatory Post-bd FEV1 still the preferred outcome Symptom assessment, e.g., MRC dyspnoea Co-morbid pathology to be documented New therapy for smoking cessation More emphasis on indoor pollution

Therapy at Each Stage of COPD I: Mild II: Moderate III: Severe IV: Very Severe FEV1/FVC < 70% FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure FEV1/FVC < 70% 30% < FEV1 < 50% predicted FEV1/FVC < 70% 50% < FEV1 < 80% predicted FEV1/FVC < 70% FEV1 > 80% predicted This provides a summary of the recommended treatment at each stage of COPD. Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed) Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Add long term oxygen if chronic respiratory failure. Consider surgical treatments

OTHER TREATMENT OPTIONS Less support for mucolytic and antioxidant therapy Pneumococcal vaccination Rehabilitation remains a key intervention Oxygen therapy reviewed Surgery and COPD guidance

COPD EXACERBATIONS COPD exacerbations defined: “An event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.” Antibiotics with specific advice NIV explained and prioritised Care at home/follow up

Dr. Chris van Weel Comments from WONCA GOLD Executive Committee President, World Organization of Family Physicians Nijmegen, The Netherlands

Global Strategy for Diagnosis, Management and Prevention of COPD Definition, Classification Burden of COPD Risk factors Pathogenesis, pathology, pathophysiology Management Practical Considerations Revised 2006

COPD Comorbidities Comorbid heterogeneity Common cause Heart failure Lung cancer Complicating Pneumonia Coincidential Diabetes mellitus Arthritis hip/knee Depression

PATIENT – DISEASE ANOMALY COPD – The Disease Airflow obstruction Function decline Continuous treatment Lifestyle Regular follow-up ‘Management plan’ Compliance Effects, safety treatment Patient with COPD Social isolation Unhealthy environment Poverty Poor self-efficacy Multiple health problems Disruptive life conditions Trust & support Safety line

VERTICAL vs HORIZONTAL PROGRAMS OF CARE HIV AIDS MALARIA TB COPD INTEGRATED PRIMARY CARE

Practical Considerations: Conclusions Link science to money Organize special programs through primary care: Ten for 2010 Make a portion (10%) of special program money available for primary care development

Dr. Claude Lenfant Closing Comments GOLD Executive Director Gaithersburg, Maryland, US

COPD: An Increasing Public Health Problem Worldwide COPD is increasing in prevalence in many countries of the world COPD is treatable and preventable The GOLD program offers a strategy to identify patients and to treat them according to the best medications available

COPD: An Increasing Public Health Problem Worldwide COPD can be prevented by avoidance of risk factors, the most notable being tobacco smoke Patients with COPD have multiple other conditions (comorbidities) that must be taken into consideration GOLD has developed a global network to raise awareness of COPD and disseminate information on diagnosis and treatment

Slovenia Germany Ireland Australia Yugoslavia Croatia Turkey Canada Bangladesh Saudi Arabia Slovenia Germany Ireland Australia Yugoslavia Croatia Turkey Canada Brazil Austria Taiwan ROC United States Portugal Thailand Malta Moldova Norway Mexico Greece China Guatemala South Africa United Kingdom Hong Kong China Italy New Zealand Tatarstan Republic Argentina France Nepal Chile United Arab Emirates Japan Peru Poland Korea Egypt Netherlands Latvia Costa Rica Venezuela Russia Republic of Georgia Switzerland Macedonia Iceland Canada Denmark Lithuania Slovakia Belgium Romania Singapore Spain Columbia Ukraine India Sweden Kyrgyzstan Vietnam Albania

World Health Organization - Global Alliance Against Chronic Respiratory Diseases - GARD

Chronic Obstructive Pulmonary Disease World COPD Day Chronic Obstructive Pulmonary Disease Press Conference Kyoto, Japan November 19, 2006