a concise workup of copd e. james britt, md common diseases are common 3rd leading cause of...

A Concise Workup of COPDE. James Britt, MD

Common diseases are common3rd leading cause of mortality

COPD is overlookedWomen > men but underdiagnosed

Core w/u is simpleWe will quickly outline an office evalWe will review goals of therapy, and how and what goals can be met today

Natural History of COPD(Fletcher and Peto)

* Death due to irreversible chronic obstructive lung disease.* Death due to irreversible chronic obstructive lung disease.Reprinted with Reprinted with permission from Fletcher C, Peto R. The natural history of chronic airflow permission from Fletcher C, Peto R. The natural history of chronic airflow obstruction. obstruction. Br Med J. Br Med J. 1977;1(6077):1645-16481977;1(6077):1645-1648

0

25

50

75

100

25 50 75

Forced Forced Expiratory Expiratory Volume inVolume in1 Second 1 Second

(FEV(FEV11))

[% of Value [% of Value at Age 25]at Age 25]

DisabilityDisability

DeathDeath

Age (Years)Age (Years)

Never smoked Never smoked or not or not susceptible to susceptible to smokesmoke

Smoke regularly Smoke regularly and susceptible and susceptible to its effectsto its effects Stopped at age 45Stopped at age 45

Stopped at age 65Stopped at age 65

** **

0

10

20

30

40

50

60

70

1980 1985 1990 1995 2000

Men Women

COPD Mortality in the United StatesNot What You Would Suspect?

1980-2000

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Mannino et al. Mannino et al. MMWR Morb Mortal Wkly Rep.MMWR Morb Mortal Wkly Rep. 2002;51(SS-6):1-16. 2002;51(SS-6):1-16.

Questioning a patient thought to have COPDCough, 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

Criteria for Diagnosis of COPD

• Clinical history– Exposure: smoke, other– Symptoms: cough, sputum, dyspnea

• Functional assessment– Spirometry (FEV1, forced vital capacity [FVC], and FEV1/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. Pauwels RA, et al, on behalf of the GOLD Scientific Committee. Am J Respir Crit Care Med.Am J Respir Crit Care Med. 2001;163:1256-1276.2001;163:1256-1276.

Prognosis of Airways Obstruction in Tuscon >age 65

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

Short Acting Bronchodilators

• Beta Agonist Family– Pro Air; Proventil; Ventolin; Albuterol;

Xopinex $40-$45

• Anticholinergic Family– Atrovent,

• Combination– Combivent; Respimat $210

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

Supplemental Medications

• Theophylline

Theophylline1

• 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.

Medications to Prevent Exacerbations

• Rofumulast $300

• Azithromycin

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

Azithromycin and COPD

• COPD consortium: UMMD/Scharf (Albert)• 250 mg AZ/d 570 patients• Time to Exacerbation extended by 92 days

– Placebo=174d Az=266d– Risk Rate

• Placebo=1.83/yr Az=1.48/yr

• Limited by ototoxicity, cardiac toxicity, drug-drug toxicity

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

Principal of Mix & MatchCombination 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

Escalating Menu of ChoicesA 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

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

Preservation of Lung function

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

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

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

Days

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-5 0 5 10 15 20 25 30 35 40 45

Exe

rcis

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seco

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491.7 sec

+ 105.2 sec + 21.4 %

+ 66.8 sec + 13.6 %

** p<0.01

* p<0.05

***

Tiotropium Exercise Trial: Endurance Time Tiotropium Exercise Trial: Endurance Time During Constant Work ExerciseDuring Constant Work Exercise

Tiotropium (n=96)Placebo (n=91)

Baseline

O’Donnell et all ERJ 2004 (in press).

ACP Clinical Practice GuidelinesCOPD

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