Prescribing in Chronic Obstructive Pulmonary Disease Sam Prigmore Respiratory Nurse Consultant St Georges’ Healthcare NHS Trust NMP Update March 2014 By 2020 COPD will be the 3rd leading cause of death from chronic disease worldwide Estimated 900,000 people in the UK have been diagnosed with COPD Estimated 2 million remain undiagnosed What is COPD? • COPD is predominantly caused by smoking and is characterised by airflow obstruction that: - is not fully reversible - does not change markedly over several months - is usually progressive in the long term • Exacerbations often occur, where there is a rapid and sustained worsening of symptoms beyond normal day-to-day variations requiring a change in treatment Chronic Bronchitis Chronic bronchitis: Inflammation of the bronchi, which carry oxygen from the air through the lungs. This inflammation increases mucus production in the airways, producing phlegm and cough Emphysema Chronic emphysema: the alveoli lose their elasticity. This reduces the support of the airways, causing them to narrow. It also means the lungs are not as good at getting oxygen into the body, so you may have to breathe harder. This can result in shortness of breath. Clinical course of COPD COPD Deconditioning Breathlessness Exacerbations Inactivity Reduced exercise capacity Poor health related quality of life Disability Disease progression Death Aims of COPD Treatment • Slow the accelerated decline in lung function • Relieve of symptoms • Improve daily function • Decrease exacerbations • Improve quality of life COPD London Respiratory Team Value Pyramid - Cost/QALY Telehealth £92000/QAL Y Triple Therapy £7000£187000/QALY Long term Oxygen Therapy £11£23000/QALY LABA £5-8000/QALY Tiotropium/LAMA £7000/QALY Pulmonary Rehabilitation £2000-8000/QALY Stop Smoking Support with pharmacotherapy £2000/QALY Flu vaccination? £1000/QALY in “at risk” population NICE guidelines and quality standards Flu and Pneumonia vaccination Smoking cessation E cigs or ‘Vapping’ The evidence…….. Bullen C et al 2013 Lancet dx.doi.org/10.1016/50140-6736(13)61842-5 • Insufficient statistical power to conclude superiority of ‘e’ cigarettes to patches or placebo • No adverse effects Bullen C et al 2013 Lancet dx.doi.org/10.1016/50140-6736(13)61842-5 Pulmonary Rehabilitation Inhaled therapies Breathlessness and exercise limitation SABA or SAMA as required* FEV1 < 50% FEV1 ≥ 50% Exacerbations or persistent breathlessness LABA LAMA (Discontinue SAMA) ________ Offer LAMA in preference to regular SAMA four times a day Persistent exacerbations or breathlessness Offer LABA + ICS in a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LABA + ICS in a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LAMA (Discontinue SAMA) ________ Offer LAMA in preference to regular SAMA four times a day LAMA + LABA + ICS in a combination inhaler * SABAs (as required) may continue at all stages Consider NICE 2010 Inhaler Technique Inhaler technique • Critical errors include – Not removing the protective cap – Not shaking the device if required – Wrong inhalation speed – Not inhaling – Not holding breath Melani A et al 2011 Resp Med 105 930-938 One size does not fit all……. • Considerations – Inspiratory effort – Dexterity – Coordination – Visual impairment – Cognitive function Broeders M et al 2009 PCRJ 18 (2) 76-82 Bronchodilators • Short acting – SABA – SAMA • Long acting – LABA – LAMA Long Acting B2 Antagonists Breathlessness FEV1 >50% • Salmeterol (serevent) – MDI, accuhaler – 50mcgs bd • Fomoterol (oxis, foridil atimos) – Turbohaler – MDI – 12mcg bd • Indacaterol (Ombrez) – Breezhaler – 150-300mg od Long Acting Muscarinic Antagonists Breathlessness FEV1 >50% • Tiotropruim (Spirva) – Handihaler (DPI)-18mcg od – Respimat (soft mist)5mcg od • Aclidinium (Eklira) – Genuair inhaler (DPI) – 400mcg bd • Glycopyrronium (Seebri) – Breezhaler (DPI) – 50mcg od Inhaled therapies Breathlessness and exercise limitation SABA or SAMA as required* FEV1 < 50% FEV1 ≥ 50% Exacerbations or persistent breathlessness LABA LAMA (Discontinue SAMA) ________ Offer LAMA in preference to regular SAMA four times a day Persistent exacerbations or breathlessness Offer LABA + ICS in a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LABA + ICS in a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LAMA (Discontinue SAMA) ________ Offer LAMA in preference to regular SAMA four times a day LAMA + LABA + ICS in a combination inhaler * SABAs (as required) may continue at all stages Consider NICE 2010 Inhaled Corticosteroids • Indications – Persistent exacerbations or breathlessness’ • FEV1 < 50% predicted • 2 or more exacerbations/ year Monotherapy not recommended • Seretide – Accuhaler 500 • Fluticasone/ salmeterol • Symbicort – Turbohaler 400/12 • Budesonide/formoterol • Relvar – Ellipta 92/22mcg • Fluticasone furoate/ vilanterol Think before you prescribe • Consider potential – Pneumonia – Systemic side effects – Steroid cards • Not licensed for COPD – Fostair, Flutiform Other medications • Mucolytics – Carbocisteine 375mg t.d.s / b.d – Mecysteine 200mg q.d.s/ t.d.s/ b.d – ??Erdonsteine 300mg b.d Acute exerbacations 10/7 • Oral Steroids – – – – Adrenal suppression Risk of comorbidities Risk/ benefit Steroid cards • Theophyllines – Theophylline – Uniphyllin – Slophyllin • Caution Other medications • Prophylactic Oral antibiotics – Azithromycin 250-500mg three times/ day – Trial for 3-6 months ??? Seasonal • Indications – Recurrent infections (2+ a year) – On triple therapy and undertaken PR – Excluded NMT and immunological issues • Cautions – – – – Potential increase in resistance (generally) Cardiac events (ECG pre) Liver toxicity (monitor LFT) Deafness Donarth E et al 2013 Resp Med 107(9) 1385-92 Herath SC, PooleP 2013 Cochrane dataBase Other medications • Prophylactic nebulised antibiotics – Colistimethate sodium (Colistin) 1 mega unit b.d – Gentamycin 80-160 mg b.d – Tobramycin 300mg b.d • Indications – Recurrent pseudomonas infections • Cautions – Bronchospasm – Resistance Nebulised Therapy • Acute • Chronic Oxygen • Oxygen is for Hypoxia not breathlessness Oxygen • Refer for assessment if – oxygen saturations less then 92%, on air – desaturation on mobilisation( < 4% from a resting saturation of 92% or lower) Exacerbation management • Prompt Treatment – – – – Antibiotics Oral Steroids Bronchodilators ? Oxygen • Appropriate venue of care – Hospital avoidance – NIV • Consider rescue packs – Not suitable for all • Review • Monitor Symptom management • Consider Non pharmacological approaches • Breathlessness – Oramorph • Anxiety – s/l lorazepam • Depression – Wide choice of anti depressants • Nutrition – Supplements Aims of COPD Treatment • Slow the accelerated decline in lung function • Relieve of symptoms • Improve daily function • Decrease exacerbations • Improve quality of life