1. A Concise Workup of COPD E. James Britt, MD Common diseases are common 3rd leading cause of mortality COPD is overlooked Women > men but underdiagnosed Core w/u is simple We will quickly outline an office eval We will review goals of therapy, and how and what goals can be met today

5. Natural History of COPD (Fletcher and Peto) * Death due to irreversible chronic obstructive lung disease. Reprinted with permission from Fletcher C, Peto R. The natural history of chronic airflow obstruction. Br Med J. 1977;1(6077):1645-1648 0 25 50 75 100 255075 Forced Expiratory Volume in 1 Second (FEV 1 ) [% of Value at Age 25] Disability Death Age (Years) Never smoked or not susceptible to smoke Smoke regularly and susceptible to its effects Stopped at age 45 Stopped at age 65 ********

6. 0 10 20 30 40 50 60 70 19801985199019952000 MenWomen COPD Mortality in the United States Not What You Would Suspect? 1980-2000 YearYear Absolute No. Deaths per 100,000 Mannino et al. MMWR Morb Mortal Wkly Rep. 2002;51(SS-6):1-16.

7. Questioning a patient thought to have COPD Cough, SOB, Chest Pain Smoker? Childhood allergies, asthma? SOB: –House/apartment, 1-3 floors? –Up/down at will; once daily; ask others? –Yard work, laundry, mail,daily errands, trapped? –Arm work? –Nocturnal attacks? Hospital or ER? Medication Review

8. Criteria for Diagnosis of COPD Clinical history –Exposure: smoke, other –Symptoms: cough, sputum, dyspnea Functional assessment –Spirometry (FEV 1, forced vital capacity [FVC], and FEV 1 /FVC ratio) –Oxygenation –Lung volumes –Diffusion capacity Anatomic assessment –Chest x-ray –High resolution CT scan Pauwels RA, et al, on behalf of the GOLD Scientific Committee. Am J Respir Crit Care Med. 2001;163:1256-1276.

9. Prognosis of Airways Obstruction in Tuscon >age 65

10. Pharmacologic RX of COPD Short Acting Bronchodilators Long Acting Maintanance Drugs Supplemental Medications Meds to Rx Exacerbations Meds to Prevent Exacerbations Medications to Preserve Lung Function Medications to Reduce Mortality

11. Short Acting Bronchodilators Beta Agonist Family –Pro Air; Proventil; Ventolin; Albuterol; Xopinex $40-$45 Anticholinergic Family –Atrovent, Combination –Combivent; Respimat $210

12. Long Acting Bronchodilators Anticholinergics –Tiotropium; Aclidinium $250 Beta Agonists Salmeterol, Formoterol, Indacaterol $250 Steroid/Beta Agonist Combinations –Advair 250/50; Salmeterol 160/4.5 $250

13. Supplemental Medications Theophylline

14. Theophylline 1 If response to initial anticholinergic/  2 -agonist therapy suboptimal, consider adding theophylline Long-acting formulations generally preferred –Modest bronchodilation, mild anti-inflammatory effects Useful for noncompliant patients and those who have trouble with inhalation aerosols and those preferring oral drugs 1. NCAP. J Respir Dis. 2000;21(suppl):S5-S21.

15. Medications to Prevent Exacerbations Rofumulast $300 Azithromycin

16. PD4 Inhibitors-Roflumilast Six and Twelve month data document decreased exacerbations in a COPD cohort with recurrent exacerbations of chronic bronchitis and use of inhalled glucorticoids Limited by headache, nausea, diarrhea and weight loss **Never gone head-head against theophylline Many in pipeline…special interest in inhalled

17. Azithromycin and COPD COPD consortium: UMMD/Scharf (Albert) 250 mg AZ/d570 patients Time to Exacerbation extended by 92 days –Placebo=174dAz=266d –Risk Rate Placebo=1.83/yrAz=1.48/yr Limited by ototoxicity, cardiac toxicity, drug-drug toxicity

18. Recommendation for Azithromycin Use in COPD >= 2 exacerbation/yr Compliant patient Pulse <100 QT<450 msec. SGOT/SGPT < 3X normal No QT drugs Hearing OK, Audiogram ? Exclude high cardiac risk patient

19. Principal of Mix & Match Combination therapy My role here is that of a shopping assistant really recommending ways in which a patient may mix and match medications to achieve goals…challenging given the $$ involved

20. Escalating Menu of Choices A moderate to severe patient Long acting anticholinergic$260 Steroid/Long act beta agonist$250 Long acting beta agonist $120 Short acting rescue drug$ 50 Preventitave drug$300

21. Prevention of Relapse Tiotropium and two Steroid/beta agonist maintanance inhalers have secondary endpoint claims from large long-term studies. Additional preventative strategies were reviewed

22. Preservation of Lung function No major studies document preservation of lung function at this time. It remains the elusive goal.

23. Statins Observations –Diminished decline in PFT –Decreased ER & H documented COPD Consortium: STATSCOPE –3 yr 1000 participants –? Direct effect on COPD –? Indirect benefit thru heart disease

24. Improve exercise performance Both long acting anticholinergics and long acting beta agonists have data that show increased esercise time and or endurance oner two months of regular use likely thru the lung volume reduction effect

27. ACP Clinical Practice Guidelines COPD Spirometry to dx airflow obstruction, but not to screen Stable FEV1 60-80% bronchodilators MAY be used Stable FEV1 <60% monotherapy with long act bd FEV1<60% Rx LAMA or LABA patient pref, cost, adverse event profile May adm combination rx for symptomatic pts Rehab for <50% FEV1 O2 for resting hypoxemia, usual guidelines