JORGE GUERREROResidente 1er añoMedicina Falimiar y

ComunitariaFarmacología Clínica

Morbidity and mortality

aimed at immediately

relieving

reducing the impact of symptoms reducin

g the ri

sk o

f futu

re

adverse h

ealth e

vents

Focus on both the short-term and long

term impact of COPD on our patients.

EPIDEMIOLOGY

11.78% (1988-1994) 15.66% (1999-2004)

14.78% (2005-2008)

Clin Gastroenterol Hepatol. 2011 Jun;9(6):524-530.e1; quiz e60. doi: 10.1016/j.cgh.2011.03.020. Epub 2011 Mar 25

DEFINITION CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Preventable Treatable

PERSISTENT

Chronic

Response not Reversible

This definition does not use the terms chronic bronchitis and emphysema and excludes asthma (reversible airflow limitation).

DEFINITION CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Chronic bronchitis, defined as the presence

of cough and sputum production for at least

3 months in each of 2 consecutive years, is

not necessarily associated with airflow

limitation.Emphysema, defined as destruction of the alveoli.

SYNTOMS OF COPD

CARDINAL SYNTOMS

WHAT CAUSE COPD ? TABACCO SMOKERS

INDOOR AIR POLLUTION

WHAT CAUSE COPD ?

Biomass fuel used for cooking and heating in poorly vented dwellings, a risk factor that particularly affects

OCCUPATIONAL DUST AND CHEMICALS

WHAT CAUSE COPD ?

OUTDOOR AIR POLLUTION

WHAT CAUSE COPD ?

Total burden of inhaled particles

DIAGNOSIS OF COPD

+ SPIROMETRY (Air flow limitation)Simple test to measure the amount of air a

person can breathe out, and the amount of time taken to do so. FVC (Forced Vital Capacity): maximum volume of air

that can be exhaled during a forced maneuver. FEV1 (Forced Expired Volume in one second):

volume expired in the first second of maximal expiration after a maximal inspiration. This is a measure of how quickly the lungs can be emptied.

FEV1/FVC: FEV1 expressed as a proportion of the FVC, gives a clinically useful index of airflow limitation.

DIAGNOSIS OF COPD

WHY DO SPIROMETRY FOR COPD?

Spirometry is needed to make a clinical diagnosis of COPD.

A normal value for spirometry effectively excludes the diagnosis of clinically relevant COPD.

Together with the presence of symptoms, spirometry helps gauge COPD severity and can be a guide to specific treatment steps.

ASSESMENT OF COPD

• Symptoms (impact on patient’s health status)

• Degree of airflow limitation (using spirometry) • Risk of exacerbations• Comorbidities

ASSESS SYMTOMS

measure clinical control self administered

measures of health status91 and predicts future mortality risk

mM

RCA - C

B - D

ASSESMENT OF COPD

• Symptoms (impact on patient’s health status)

• Degree of airflow limitation • Risk of exacerbations• Comorbidities

DEGREE OF AIR FLOW LIMITATION

ASSESMENT OF COPD

• Symptoms (impact on patient’s health status)

• Degree of airflow limitation • Risk of exacerbations• Comorbidities

CONCEPT. Acute event. Worsening of the patient’s respiratory symptoms. leads to a change in medication.

ASSESSMENT OF RISK OF EXACERBATIONS

The best predictor of having frequent

exacerbations

=

Previous Exacerbations2 0R MORE PER YEARGOLD 2 + Exace

rbatio

ns = G

OLD 3 0r 4

ASSESMENT OF COPD

• Symptoms (impact on patient’s health status)

• Degree of airflow limitation • Risk of exacerbations• Comorbidities

ASSESSMENT OF COMORBIDITIES

ASSESMENT OF COPD

• Symptoms (impact on patient’s health status)

• Degree of airflow limitation • Risk of exacerbations• Comorbidities

COMBINED COPD ASSESMENT

• Symptoms (impact on patient’s health status)

• Degree of airflow limitation • Risk of exacerbations• Comorbidities

COMBINED COPD ASSESMENT

When assessing risk, choose the highest risk according to GOLD

grade or exacerbation history. (One or more hospitalizations

for COPD exacerbations should be considered high risk.

Patient Group A – Low Risk, Less Symptoms

Typically GOLD 1 or GOLD 2 (Mild or Moderate airflow limitation) and/or 0-1 exacerbation per year and mMRC grade 0-1 or CAT score < 10

Patient Group B – Low Risk, More Symptoms

Typically GOLD 1 or GOLD 2 (Mild or Moderate airflow limitation) and/or 0-1 exacerbation per year and mMRC grade ≥ 2 or CAT score ≥ 10

Patient Group C – High Risk, Less Symptoms Typically GOLD 3 or GOLD 4 (Severe or Very

Severe airflow limitation) and/or ≥ 2 exacerbations per year and mMRC grade 0-1 or CAT score < 10

Patient Group D – High Risk, More

Symptoms Typically GOLD 3 or GOLD 4 (Severe or Very

Severe airflow limitation) and/or ≥ 2 exacerbations per year and mMRC grade ≥ 2 or CAT score ≥ 10

Example: Imagine a patient with a CAT score of 18, FEV1 of 55% of predicted, and a history of 3 exacerbations within the last 12 months.

Example: Imagine a patient with a CAT score of 18, FEV1 of 55% of predicted, and a history of 3 exacerbations within the last 12 months.

TO BE CONTINUED…

TRATAMIENTO

ABANDONO DEL TABAQUISMO

Mayor capacidad de intervencion en la historia natural del EPOC.

Vareniclina

EJERCICIO CARDIOVASCULAR

TRATAMIENTO FARMACOLOGICO

Reducir los sintomas.Reduce la frecuencia y severidad de las exacerbaciones.

Controla la tolerancia para el inicio del ejercicio.

Terapia Individualizada.Disponibilidad del medicamento.Costo del medicamentoRespuesta por parte del paciente

TRATAMIENTO FARMACOLOGICO

Acerca de la Preescripción

BRONCODILATADORES

Fundamental para el CONTROL de SÍNTOMAS

Se prefiere por vía Inhalada La escogencia entre: beta-2-agonists,

anticolinergicos, teofilina o terapia combinada…’ Los de larga acción, producen mayor tiempo,

libre de síntomas. Combinacion de broncodilatadores de clase

farmacológica diferente disminuye el riesgo de efectos secundarios.

TRATAMIENTO FARMACOLOGICO

TRATAMIENTO FARMACOLOGICO

CORTICOIDES INHALADOS

Pacientes con FEV1< 60%.Tratamiento regular: Disminuye los

síntomas.Relacionados con aumento

Incidencia de Neumonía.NO usar en monoterapia.

CORTICOIDES ORALES

No usar tratamiento a largo plazo con corticosteroide oral.

TRATAMIENTO FARMACOLOGICO

METILXANTINAS (Bloqueo R Adenosina)

Menos efectivas y toleradas que los broncodilatadores de larga acción.

La adición de Teofilina con Salmeterol, aumento en el VEF1 y alivio de la disnea.

Bajas dosis de Teofilina disminuye los síntomas, mas no la función pulmonar.

TRATAMIENTO FARMACOLOGICO

TRATAMIENTO FARMACOLOGICO

INHIBIDORES 4-P-DIESTERASA (AMPc)

Reduce las exacerbaciones en sinergismo con los corticoides orales o broncodilatadores de larga acción.

TRATAMIENTO FARMACOLOGICO

AGENTES MUCOLÍTICOSPacientes con esputo viscoso, se

benefician, sin embargo los beneficios son leves.

AGENTES ANTITUSIVOS

TRATAMIENTO FARMACOLOGICO

Example: Imagine a patient with a CAT score of 18, FEV1 of 55% of predicted, and a history of 3 exacerbations within the last 12 months.

TRATAMIENTO FARMACOLOGICO

TRATAMIENTO FARMACOLOGICO

OTROS TRATAMIENTOS

USO DE VACUNAS

OTROS TRATAMIENTOS

PaO2 menor (55 mmHg) or SaO2 88%,

con o sin hipercapnia confirmada dos

veces en un periodo de 3 semanas.

PaO2 entre (55 mmHg) y (60 mmHg), o

SaO2 of 88%, con evidencia de HTP,

edema periferico sugestivo de ICC, o

policitemia (hematocrito > 55%).

EXACERBACIONES