Transcript COPD: wat is er nieuw

COPD: wat is er nieuw?
V. Nowé
Topics
• Begin: = oud (GOLD 2011)
• Wat is er naast GOLD?
– GOLD C – D: iedereen IHC?
•
•
•
•
Effect op exacerbaties?
Pneumonie?
Dosis IHC?
Afbouwen mogelijk en bij wie?
– Azithromycine: wie?
• Nieuwe inhalatoren
• Pneumococcenvaccin
• Acetylcysteïne
GOLD
• COPD aanpak/behandeling:
• Doel:
a five-year
mortality rate of
about
50%
– Symptomen verminderen (Korte termijn)
– Verminderen van exacerbaties/hospitalisaties
(Lange termijn)
• Exacerbaties/hospitalisatie
• Sneller achteruitgang Lf
• Gedaalde fysische
activiteit/inspanningstoleran
tie
• Gedaalde QOL
• Verhoogd risico op
overlijden
• GOLD 2001 -2015
• Aanpassing
– 2001: COPD obv ernst (FEV1): stadia I-IV
• GOLD 2001 - 2015
• Aanpassing
– 2001: COPD obv ernst (FEV1): stadia I-IV
– 2011: FEV1 niet betrouwbare marker voor ernst
van symptomen (dyspnoe, inspanningsbeperking,
exacerbatierisico, hospitalisatierisico, overlijden)
• --> GOLD klassen A-B-C-D
– 2013,2014 en 2015 updates
• GOLD 2015: klassen
– Symptomen
– Risico’s op exacerbaties
– Ernst longfunctie afwijkingen
• GOLD 2015: therapie
– Klasse
– Comorbiditeit
ECLIPSE: Verhoogd risico op exacerbaties: heterogeniteit
ECLIPSE
In eerste
jaar vd
studie
Sterk geassocieerd met
exa in voorafgaande jaar
29%
Geen exa
in 3 jaar
Geen exa
in
voorgaand
e jaar
Global Strategy for Diagnosis, Management and Prevention of COPD
GOLD 4
Manage Stable COPD: Pharmacologic Therapy
RECOMMENDED FIRST CHOICE
C
ICS + LABA
or
LAMA
GOLD 3
GOLD 2
GOLD 1
D
2 or more
or
> 1 leading
to hospital
admission
ICS + LABA
and/or
LAMA
A
B
SAMA prn
or
SABA prn
LABA
or
LAMA
1 (not leading
to hospital
admission)
0
CAT < 10
mMRC 0-1
CAT > 10
mMRC > 2
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Exacerbations per year
GOLD
GOLD
• Symptomen
Global Strategy for Diagnosis, Management and Prevention of COPD
Modified MRC (mMRC)Questionnaire
© 2014 Global Initiative for Chronic Obstructive Lung Disease
GOLD
Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Key Points
 Appropriate pharmacologic therapy can reduce COPD
symptoms, reduce the frequency and severity of
exacerbations, and improve health status and
exercise tolerance.
 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.
 Smoking cessation
GOLD

Global Strategy for Diagnosis, Management and Prevention of COPD
Therapeutic Options: Bronchodilators
Bronchodilator medications are central to the
symptomatic management of COPD.
 Bronchodilators are prescribed on an as-needed or on a
regular basis to prevent or reduce symptoms.
 The principal bronchodilator treatments are beta2-
agonists, anticholinergics, theophylline or combination
therapy.
 The choice of treatment depends on the availability of
medications and each patient’s individual response
in terms of symptom relief and side effects..
© 2014 Global Initiative for Chronic Obstructive Lung Disease
Global Strategy for Diagnosis, Management and Prevention of COPD
GOLD
Therapeutic Options: Inhaled
Corticosteroids

Regular treatment with inhaled corticosteroids
improves symptoms, lung function and quality of life
and reduces frequency of exacerbations for COPD
patients with an FEV1 < 60% predicted.

Inhaled corticosteroid therapy is associated with an
increased risk of pneumonia.

Withdrawal from treatment with inhaled
corticosteroids may lead to exacerbations in some
patients.
Wat weten we naast GOLD?
2) ICS + LABA +
LAMA
3
2
1
≥2
SAMA or
SAAB
SOS
mMRC < 2
CAT < 10
1
LAMA or
LABA
mMRC ≥ 2
CAT ≥ 10
Symptoms
(mMRC or CAT score)
0
(Exacerbation history)
1) ICS + LABA or
LAMA
4
Risk
(GOLD Classification of Airflow Limitation)
Spirometry
Management of COPD according to Symptoms,
Spirometric classification and Future Risk of Exacerbations
Effect of ICS on exacerbations
(moderate and severe)
Mean number of exacerbations/year
1,2
1,13
17% reduction
0,97*
1
0,93*
0,85*†‡
0,8
0,6
0,4
0,2
0
Placebo
SALM
FP
SALM/FP
Calverley P. et al. NEJM 2007.
Exacerbations requiring hospital admission
Mean number of severe exacerbations/year
0,25
0,2
0,19
0,16*
0,17
SALM
FP
0,16†
0,15
0,1
0,05
0
Placebo
SALM/FP
Calverley P. et al. NEJM 2007.
In COPD, hoe verhoudt zich
het risico van ICS tov het voordeel van ICS?
A. NNH << NNT
B. NNH < NNT
C. NNH = NNT
D. NNH > NNT
E. NNH >> NNT
NNH: Number Needed to Harm
NNT: Number Needed to Treat
In COPD, hoe verhoudt zich
het risico van ICS tov het voordeel van ICS?
A. NNH << NNT
B. NNH < NNT
C. NNH = NNT
D. NNH > NNT
E. NNH >> NNT
NNH: Number Needed to Harm
NNT: Number Needed to Treat
______________
ICS in COPD: risk of pneumonias
= NNH
Suissa S., Thorax 2012.
ICS in COPD: risk of pneumonia
Price D. et al, PCRJ 2013.
Wat is de optimale dosis ICS bij COPD?
A. Budesonide 2x 400 = 800 µg
B. Fluticason dipropionaat 2x 100 = 200 µg
C. Fluticason dipropionaat 2x 250 = 500 µg
D. Fluticason dipropionaat 2x 500 = 1.000 µg
E. Fluticason furoaat 1x 50 = 50 µg
F. Fluticason furoaat 1x 92 = 92 µg
G. Fluticason furoaat 1x 184 = 184 µg
Wat is de optimale dosis ICS bij COPD?
A. Budesonide 2x 400 = 800 µg ?
B. Fluticason dipropionaat 2x 100 = 200 µg
C. Fluticason dipropionaat 2x 250 = 500 µg
?
D. Fluticason dipropionaat 2x 500 = 1.000 µg
E. Fluticason furoaat 1x 50 = 50 µg
F. Fluticason furoaat 1x 92 = 92 µg
G. Fluticason furoaat 1x 184 = 184 µg
In patiënten met COPD *
leidt stoppen van ICS tot:
A.
B.
C.
D.
E.
Exacerbaties
Frequente exacerbaties
Mortaliteit
Depressie
Geen van bovenstaande antwoorden
* behandeld met tripple therapie
LABA + ICS)
(LAMA +
In patiënten met COPD *
leidt stoppen van ICS tot:
A.
B.
C.
D.
Exacerbaties
Frequente exacerbaties
Mortaliteit
Depressie
E.
Geen van bovenstaande antwoorden
* behandeld met triple therapie
LABA + ICS)
(LAMA +
WISDOM trial
_____
WISDOM trial: exacerbations
Magnussen H. et al, NEJM 2014.
Volgens GOLD
• Withdrawal from treatment with inhaled
corticosteroids may lead to exacerbations in
some patient, although in another study with
severe and very severe COPD patients, inhaled
corticosteroids could be gradually withdrawn
over a three-month period without increasing
the medium term risk of exacerbations,
although lung function deteriorated
significantly.
Azithromycin prevents exacerbations of COPD
Albert R. et al, NEJM 2011.
Stepwise treatment of COPD according to
Severity: spirometry, symptoms, exacerbations
Reliever:
SAMA
or
SABA
Maintenance:
LAMA
or
LABA
STEP 1
STEP 2
Spiro 1 or 2
Spiro 1 or 2
mMRC
mMRC ≥ 2
SABA <± 2SAAC SOS
No exac
≤ 1 exac
Maintenance:
LAMA
and
LABA
Maintenance:
LAMA
and
LABA
Plus:
1) ICS
and/or
2) AZI
STEP 3
Spiro 3 or 4
≤ 1 exac
STEP 4
Spiro 2, 3 or 4
mMRC ≥ 2
≥ 2 exac
Smoking cessation
Vaccination
(influenza)
Patient education
Self-management
Pulmonary
rehabilatation: if
mMRC ≥ 2
Oxygen therapy:
if PaO2 < 60 mmHg
Nieuwe inhalatoren
• Zie hand-outs
LAMA
ICS+LABA
LAMA+LABA
Pneumococcen vaccin?
• GOLD
– Influenza vaccines can reduce serious illness.
Pneumococcal polysaccharide vaccine is
recommended for COPD patients 65 years and
older and for COPD patients younger than age 65
with an FEV1 < 40% predicted
• Hoge raad
– Nieuwe publicatie 10/2/2015
– Aanpassingen obv Capita studie
Acetylcysteïne
• GOLD 2015
– Hoge dosis NAC: significant minder exa in GOLD II
• Pantheon Lancet 2014
PANTHEON-studie:
The Lancet, 2014
Resultaten 6
Aantal exacerbaties per behandelingsperiode
COPD-patiënten in GOLD-stadia II en III
-22%
6. Zhen J-P, et al. Twice daily N-acetylcysteine 600 mg for exacerbations of chronic obstructive pulmonary disease (PANTHEON):
a randomised, double-blind placebo-controlled trial. Lancet Respir Med. 2014 Mar;2(3): 187-94.
Zambon
Gamme
10 tabs
Mode d’action
Objectifs
Méthode
Résultats
Conclusion
Objectifs
Méthode
Résultats
Conclusions
Résumé
Notices
PANTHEON-studie:
The Lancet, 2014
Resultaten 6
Jaarlijks aantal exacerbaties per GOLD-stadium
-39%
NAC vermindert het jaarlijks aantal
exacerbaties van COPD-patiënten
in GOLD-stadium II (matig) met 39 %
NAC 1200 mg vs Placebo - Gold Mod.
< 0.0001
0.61 (0.48,0.77)
VERBETERING VAN DE KLINISCHE TOESTAND VAN DE PATIËNT
IN DE GOLD-STADIA II EN III
6. Zhen J-P, et al. Twice daily N-acetylcysteine 600 mg for exacerbations of chronic obstructive pulmonary disease (PANTHEON):
a randomised, double-blind placebo-controlled trial. Lancet Respir Med. 2014 Mar;2(3): 187-94.
Zambon
Gamme
10 tabs
Mode d’action
Objectifs
Méthode
Résultats
Conclusion
Objectifs
Méthode
Résultats
Conclusions
Résumé
Notices
Take home messages
• Nieuwe GOLD: leiddraad
• Maar in GOLD C en D
– LAMA+LABA staan op de eerste plaats bij GOLD C-D
– IHC pro’s en con’s
• Dosis te hoog?
• WISDOM: 1 jaar geen exacerbatie --> afbouwen = veilig
– COLUMBUS: Azithromycine: >= 2-3 exa per jaar
• NAC in GOLD 2: significante daling van
exacerbaties
• Pneumococcen vaccinatie: nieuwe aanbeveling
van de Hoge Raad