1. Nottinghamshire COPD and Asthma Guidelines Dr Esther Gladman GP Prescribing Lead, Medicines Management Nottingham City CCG Feb 2012

2. Where to find & other resources Google:Nottinghamshire Area Prescribing Committee – Medicines Traffic Light Classification List Medicines Traffic Light Classification List – Shared Care Protocols Shared Care Protocols – Clinical Guidelines Clinical Guidelines – Formularies Formularies – Policies and Prescribing Position Statements Policies and Prescribing Position Statements E-healthscope www.patient.co.uk www.prodigy.nhs.uk (was CKS) www.prodigy.nhs.uk

3. e.g. from prodigy : What simple measures can I advise to manage breathlessness for people with end-stage COPD? Advise the person on the following simple measures to manage breathlessness. – Sitting in front of a fan or open window (or using a hand-held fan). – Positioning For example, advise the person to sit or stand leaning forward (for example onto a table or the back of a chair) and supporting their weight with their arms and upper body. – Pursed-lip breathing Advise the person to inhale through the nose and then exhale slowly, for 4– 6 seconds, through pursed lips. Other simple measures, not specific to chronic obstructive pulmonary disease (COPD) but recommended in the section on Simple measures to help dyspnoea in the PRODIGY topic on Palliative cancer care - dyspnoea, may be useful for people with COPD. Simple measures to help dyspnoea Palliative cancer care - dyspnoea

4. Nottinghamshire COPD Guideline Key points Most effective interventions Be aware other conditions Effective/cost effective prescribing Steroid dose, pneumonia & adverse Be aware side effects and adverse effects of meds Where can you make a difference?

5. Most Effective Interventions 1. Stopping smoking is the only treatment that slows the progression of COPD and is the most cost effective treatment in COPD. NNT 5 –to prevent death at age 70 Motivational questioning, cost cigs & inhalers, Allen Carr, anxiety, dopamine,worsening of symptoms, dementia

6. Most Effective Interventions: 2. Pulmonary Rehabilitation MRC dyspnoea score 3, 4, 5 or recent admission “more breathless than contemporaries when walking or gets breathless on exertion & needs to rest” – NNT 2 to improve exercise tolerance by a clinically useful amount – NNT 4 to stop readmission over 6/12 if given early after an exacerbation

7. Most Effective Interventions 3. Self Management Plans NNT 10 to reduce admission in low risk patients NNT 3 to reduce admission in high risk patients (1 previous admission or LTOT or previous use of Prednisolone) NNT 5 for patient held “emergency supply pack” (prednisolone +/- antibiotic) to reduce admission

8. Beware diagnosis >40 years old Smoker or ex-smoker, non-smoking spouse of smoker or dusty occupation Spirometry FEV1 < 80% predicted and post bronchodilator FEV1/FVC ratio < 70% and typical symptoms NB FEV1 – an increase of >400ml after bronchodilator suggests asthma not COPD Consider CXR/FBC, ECG for alternative diagnoses or red flag symptoms such as haemoptysis

9. Be aware: are symptoms in accord with severity of COPD? – FEV1 Rapid decline? e.g. >200ml in 3 years, exacerbations/Excess sputum – Re-assess for co-morbidity, treatment adherence, inhaler technique Consider bronchiectasis check sputum for unusual organisms/Acid & Alcohol Fast bacilli ? Ca CXR,FBC,ECG NB 25 % will have IHD/ cardiac failure

11. Effective/cost effective prescribing Stop smoking Optimise inhaler technique (e.g. spacers with MDIs) Consider stopping new treatment if patient feels no improvement (4 weeks) – longer may be needed for a reduction in exacerbations Consider stepping down/swopping

12. Effective/cost effective prescribing LABA vs LAMA – there is no significant difference re: reduction in exacerbation or hospitalisation rates.

13. Effective/cost effective prescribing There is no combination MDI licensed for COPD However if patient preference: – Fostair 100/6 (2 puffs BD £29.32) – or Seretide 125 + spacer (2puffs BD, £35) can be considered, which gives similar ICS dose to Accuhaler 500. NB Seretide 250 MDI is not recommended

14. Adverse effects of steroid High dose ICS (ie fluticasone 1000 mcg = Seretide 250) increases the risk of pneumonia, NNH = 47 ie. Beware those with frequent exacerbations Other steroid effects - Diab/thrush/cataracts Osteoporosis prophylaxis for patients having 4 courses of oral steroid within 12 months

15. Be aware side effects and adverse effects of meds Use tiotropium Spiriva Handihaler® (18 mcg/day) not Spiriva Respimat® (mist device) All patients must be advised not to exceed the maximum daily dose All anticholinergics have some cardiovascular effect Fometerol and beta agonists also have effect

16. NBs Mucolytic only if troublesome phlegm: carbocisteine 750mg TDS (£24.60) can be trialled for 4 weeks. – Stop if no effect. – Drop to maintenance dose: 750mg BD if effective. – Consider using in winter months only. – Mucolytics do not prevent exacerbations Consider theophylline 3rd line: Uniphyllin 200mg BD (£2.94) care with elderly & concomitant medications see BNF. Theophylline levels? NNT=33

17. NBs 25% will have co-morbidity e.g. IHD/cardiac failure. Beta blockers can be used in COPD Dose of emergency supply pack?

18. Actions Flu & pneumococcal vaccination Inhaler use/Medication /step Stop smoking advice /refer New Leaf Patient info/empowerment MRC dyspnoea score 3, 4 or 5/functional disability refer for pulmonary rehabilitation Self management plan and anticipatory prescription pack Weight/diet/exercise. Little & often leaflets

19. Oxygen Sat ≤92% - refer to chest clinic /oxygen assessment service Palliative Care Planning If end-stage COPD/cor pulmonale

20. Nottinghamshire Adult Asthma Treatment Summary Micro break & shake

21. Nottinghamshire Asthma Guideline Key points Step up and down Use LABA and ICS in a combination inhaler Be aware of inhaler equivalent steroid doses Step 3a is addition of LABA not increase ICS too Twitchiness of asthma Same steroid risks as for COPD Pros & cons of SMART Theophylline levels/interactions

22. Step Consider stepping up if: 1. Using SABA 3 times a week or more 2. Symptoms 3 or > times x week 3. An exacerbation in the last 2 years 4. Waking due to symptoms one night a week Ensure adherence and inhaler technique Consider stepping down if : Asthma control has been good for 3 months on current therapy N.B. Steroid dose reductions should be slow as patients deteriorate at different rates. Reduce by 25-50% & monitor

23. Appropriate spacer/ Other devices? Peak flow meter?

26. Step 3a nb add LABA only

27. Step 3b & c

28. Step 3 alternative

29. SMART Pros: opener & reliever, inc dose steroid when need it Cons: device, symptoms, side effects

30. Step 4 asthma nb this is where use of Seretide 250 MDI is appropriate

32. nb Oral steroid - sometimes higher dose & shorter course than COPD Same steroid risks as for COPD Written Self-Management Plan/lifestyle/house dust mite/patient beliefs/info Co-morbidity

33. Key points summary Step up and down Always give LABA and ICS in combination inhaler (unlike COPD) Step 3a is addition of LABA not increase ICS too Be aware potency of ICS Inhaler and equivalent steroid doses