1. Medicines Management – COPD update for LPC Jyoti Saini Hema Patel
September 2017

2. Key issues Epidemiology
Tools to support clinicians with assessing symptoms
Place in therapy for new drugs
Update on new devices / inhalers
Treatment pathway

3. Epidemiology
About 3 million people have chronic obstructive pulmonary disease (COPD) in the UK
Nearly 900,000 people in England and Wales are diagnosed as having COPD and an estimated 2 million people have COPD which remains undiagnosed
In Walsall 2014/15 QoF reported COPD prevalence was 2.5%
Symptoms usually develop insidiously making it difficult to determine the true prevalence of the disease
Most patients are not diagnosed until they are in their fifties
Chronic obstructive pulmonary disease (updated). Clinical guideline CG101: June. National Institute for Health and Clinical Excellence

4. COPD prevalence

5. COPD
COPD is predominantly caused by smoking and is characterised by airflow obstruction that: - is not fully reversible - does not change markedly over several months - is usually progressive in the long term
Exacerbations often occur, where there is a rapid and sustained worsening of symptoms beyond normal day-to-day variations requiring a change in treatment
COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have limited or no impact on the airflow obstruction.

6. Natural History
The Fletcher-Peto Diagram, illustrating the effects of smoking on rate of decline in FEV1
Fletcher C, Peto R, The natural history of chronic airflow obstruction, British Medical Journal, 1: , 1977.

7. Diagnosis of COPD Consider a diagnosis of COPD for people who are:
over 35, and are
smokers or ex-smokers, and
have any of these symptoms:
exertional breathlessness
chronic cough
regular sputum production,
frequent winter ‘bronchitis’
wheeze
and no clinical features of asthma

8. COPD Assessment Test (CAT)
Validated, short (8-item) and simple patient completed questionnaire developed to measure health status of COPD patients
Developed by multidisciplinary groups of international experts
Has been validated in prospective studies and available in more than 50 languages
Recommended that patients complete questionnaire when they arrive for their appointment or immediately before attending
Has a scoring range of 0-40 and patients may complete every 2-3 months to detect changes and trends in CAT score

9. COPD Assessment Test (CAT)

10. CAT scores

11. Overview of management
Encourage smokers to stop
Offer drug treatment with inhalers
Consider referral for pulmonary rehabilitation
Consider a mucolytic or theophylline
Advise an annual influenza vaccination and a once-only pneumococcal vaccination
Reduces hospitalization and death rates in elderly people with chronic lung disease.

12. CCG prescribing trend – volume

13. CCG prescribing trend – spend

14. COPD – comparison of cost/QALY
Stop Smoking Support with pharmacotherapy
£2,000/ quality adjusted life-years (QALY)
Pulmonary Rehabilitation
£2,000-8,000/QALY
Tiotropium
£7,000/QALY
LABA
£5,000-8,000/QALY
Triple Therapy
£7,000 to £187,000/QALY

15. GP / Practice Pharmacist Work Plans
Brand prescribing of inhalers
Step down therapy or step across to a cost-effective inhaler
Switching inhalers for asthma and COPD - to reflect license
Tiotropium/Spiriva switched to Braltus

16. Economic considerations
Device
Spiriva Handihaler (device and 30 capsules)
Spiriva Handihaler (refill - 30 capsules)
Braltus (device and 30 capsules)

17. Any