1. © IPCRG 2007 COPD -Management of stable disease WONCA meeting Istanbul October 2015 Svein Høegh Henrichsen Oslo, Norway

2. Page 2 - © IPCRG 2012 Principles of management in stable COPD Patient education Smoking cessation Non-pharmacologic treatment Pharmacologic treatment Ikke farmakologisk behandling

3. Page 3 - © IPCRG 2012  Smoking cessation has the greatest capacity to influence the natural history of COPD. Health care providers should encourage all patients who smoke to quit.  None of the existing medications for COPD has been shown conclusively to modify the long-term decline in lung function.  Influenza and pneumococcal vaccination should be offered depending on local guidelines. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Key Points © 2015 Global Initiative for Chronic Obstructive Lung Disease

4. Page 4 - © IPCRG 2012 Patient education/ rehabilitation Patient involvement improves outcomes and adherence to treatment. oReduce riskfactors = smoking cessation –Quit smoking ASK- Advice on pharmacologic treatment –ACT –Flu vaccine and pneumococcal vaccine oCheck device use (at each consultation) oExacerbations – when to act and how Written self-management plan (oral corticosteroids and antibiotics at home) oPhysical activity

5. Page 5 - © IPCRG 2012 Therapeutic Options: Key Points  All COPD patients benefit from regular physical activity and should repeatedly be encouraged to remain active.  Patients should be refered to pulmonary rehabilitation at an early stage (MMRC 2)

6. Page 6 - © IPCRG 2012 8 Average time work (minutes) 10 14 16 24 12 18 20 22 5 139711 13 172521192315 16% 32% 42% * * rehabilitation Usual care n=44 Tiotropium n=47 Weeks n=91 *p<0,05 Effect of pulmonary rehabilitation and bronchodilatation:

7. Page 7 - © IPCRG 2012  Relieve symptoms  Improve exercise tolerance  Improve health status  Prevent disease progression  Prevent and treat exacerbations  Reduce mortality Reduce symptoms Reduce risk Goals of therapy for stable COPD

8. Page 8 - © IPCRG 2012 Expiratory reserve volume Tidal volume Residual volume Normal lungs IC TLC EILV EELV COPD IC EELV EILV TLC Exercise Inspiratory reserve volume 1 2 3 4 1 2 3 4 Price D, Freeman D, Kaplan A, Østrem A, Reid J, van der Molen T. Primary Care Resp J. 2005;14:285-293

9. Page 9 - © IPCRG 2012 Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Key Points Beta 2 -agonists Bronchodilatators Short-acting beta 2 -agonists SABA Long-acting beta 2 -agonists LABA Anticholinergics Bronchodilatators Short-acting anticholinergics SAMA Long-acting anticholinergics LAMA Combination short-acting beta 2 -agonists + anticholinergic in one inhaler Methylxanthines Inhaled corticosteroids ICS / anti-inflammatory Combination long-acting beta 2 -agonists + corticosteroids in one inhaler Systemic corticosteroids Only short-time treatment for exacerbations Phosphodiesterase-4 inhibitors

10. Page 10 - © IPCRG 2012 Treatment options COPD according to GOLD guidelines 2015 Patient group Non-pharmacologic treatment First choice Alternative choice A SAMA prn or SABA prn LAMA or LABA or SABA and SAMA B LAMA or LABA LAMA and LABA C ICS + LABA or LAMA LAMA and LABA or LAMA and PDE4-inh. or LABA and PDE4-inh. D ICS + LABA and/or LAMA ICS + LABA and LAMA or ICS+LABA and PDE4- inh. or LAMA and LABA or LAMA and PDE4-inh. Smoking cessation Flu vaccination Physical activity Pulmonary rehabilitation

11. Page 11 - © IPCRG 2012 CD AB BMRC <2 CAT<10 CCQ<1 BMRC ≥2 CAT≥10 CCQ≥1 Assess symptoms first few Symptoms A lot symptoms

12. Page 12 - © IPCRG 2012 A: few symptoms, low risk, mild disease Patient groupFirst choice Alternative choice A SAMA prn or SABA prn LAMA or LABA or SABA and SAMA Long-acting inhaled bronchodilators are convenient and more effective for symptom relief than short-acting bronchodilators.

13. CD AB III IV II I ≥2 1 0 GOLD stage Exacerbations Assess risk next low Risk High Risk

14. Page 14 - © IPCRG 2012 B: More symptoms, low risk Patient groupFirst choice Alternative choice B LAMA or LABA LAMA and LABA  Long-acting inhaled bronchodilators reduce exacerbations and related hospitalizations and improve symptoms and health status.  Combining bronchodilators of different pharmacological classes may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single bronchodilator.

15. Page 15 - © IPCRG 2012 C: more severe disease, few symptoms high risk Patient groupFirst choice Alternative choice C ICS + LABA or LAMA LAMA and LABA or LAMA and PDE4-inh. or LABA and PDE4-inh.  Bronchodilator medications are central to the symptomatic management of COPD  Regular treatment with inhaled corticosteroids improves symptoms, lung function and quality of life and reduces frequency of exacerbations for COPD patients with an FEV 1 < 60% predicted.  Inhaled corticosteroid therapy is associated with an increased risk of pneumonia. You might consider

16. Page 16 - © IPCRG 2012 D: High risk,more symptoms Patient groupFirst choice Alternative choice D ICS + LABA and/or LAMA ICS + LABA and LAMA or ICS+LABA and PDE4-inh. or LAMA and LABA or LAMA and PDE4-inh.  An inhaled corticosteroid combined with a long-acting beta 2 - agonist is more effective than the individual components in improving lung function and health status and reducing exacerbations in moderate to very severe COPD.  Addition of a long-acting beta 2 -agonist/inhaled glucorticosteroid combination to an anticholinergic (tiotropium) appears to provide additional benefits.

17. Page 17 - © IPCRG 2012  In patients with severe and very severe COPD (GOLD 3 and 4) and a history of exacerbations and chronic bronchitis, the phospodiesterase-4 inhibitor, roflumilast, reduces exacerbations treated with oral glucocorticosteroids. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Phosphodiesterase-4 Inhibitors © 2014 Global Initiative for Chronic Obstructive Lung Disease

18. Page 18 - © IPCRG 2012 COPD Assesment: Co-morbidities COPD patients are at increased risk for: Cardiovascular diseases Osteoporosis Respiratory infections Anxiety and Depression Diabetes Lung cancer These comorbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately.

19. Svein Høegh Henrichsen Norwegian College of General Practitionners Working Group on Respiratory Diseases Exacerbations To many patients are still not diagnosed until they are admitted with severe respiratory problems - Many of them already have severe disease with a bad prognosis: 9% acute mortality is 9% 3 months mortality is 19% 1 year mortality after discharg is 36% 25% of all deaths in this group are in the ages under 65 years and are considered preventableår Nanna Eriksen et al: Ugeskrift for Læger 2003; 165: 3499-502

20. Svein Høegh Henrichsen AIMEF BARI 2008 - © IPCRG 2007 How do we diagnose exacerbations?

21. Page 21 - © IPCRG 2012 What is an acute COPD exacerbation? o“A sustained worsening of the patient's condition, from the stable state and beyond normal day-to-day variations, that is acute in onset and necessitates a change in regular medication in a patient with underlying COPD”

22. Page 22 - © IPCRG 2012 Group A Patients with no acute exacerbations Group B Patients with 1–2 acute exacerbations of COPD requiring hospital management Group C Patients with ≥3 acute exacerbations of COPD requiring hospital management Time (months) 0 10 20 30 405060 0.2 0.4 0.6 0.8 1.0 Probability of surviving p <0.0001 A B C p =0.069 p <0.0002 Soler-Cataluña et al. Thorax 2005; 60:925-931. ≥3 acute exacerbations requiring hospitalisation is associated with a risk of death 4.30 times greater than for those patients not requiring hospitalization Worse Prognosis in Frequent Exacerbators

23. Page 23 - © IPCRG 2012 Oxygen: titrate to improve the patient’s hypoxemia with a target saturation of 88-92%. Bronchodilators: Short-acting inhaled beta 2 -agonists with or without short-acting anticholinergics are preferred. Systemic Corticosteroids: Shorten recovery time, improve lung function (FEV 1 ) and arterial hypoxemia (PaO 2 ), and reduce the risk of early relapse, treatment failure, and length of hospital stay. A dose of 40 mg prednisone per day for 5 days is recommended. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: Treatment Options © 2014 Global Initiative for Chronic Obstructive Lung Disease

24. Page 24 - © IPCRG 2012 Should we use antibiotics?

25. Page 25 - © IPCRG 2012 Antibiotics should be given to patients with:  Three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence.  With increased crp-values/signs of bacterial infection  Who require mechanical ventilation. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: Treatment Options © 2014 Global Initiative for Chronic Obstructive Lung Disease

26. Page 26 - © IPCRG 2012 Consider appropriate exacerbation prevention strategies Consideration and management of comorbidities Adapted from Hurst and Wedzicha. BMC Medicine 2009; 7:40. Increase in dose/frequency of inhaled bronchodilators Systemic corticosteroids Antibiotics (if change in sputum) Increasing severity Management of COPD Exacerbations Patient use of custom action plan Prevent and treat respiratory failure Oxygen (low concentrations to prevent hypercapnia) Follow-up visit 48-72 hours Consider BIPAP 26

27. Page 27 - © IPCRG 2012 Patient Action Plans Action plans are designed to Action plans are designed to 2,3 oHelp patients recognise a deterioration in their symptoms oInitiate changes to treatment early oReduce the impact of the exacerbation Developed in partnership with patients and caregivers to provide guidance for handling exacerbations 3,4 Regular respiratory medication and actions to remain stable Symptom recognition and actions to manage exacerbations A list of contacts Actions for symptom worsening or dangerous situations 27

28. Page 28 - © IPCRG 2012

29. Page 29 - © IPCRG 2012 Thank you for your attention!