Agenda I. Welcome and Introduction II. Screening Initiatives and - - PDF document

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Assessm ent and Managem ent of COPD Patients in Prim ary Care: Tools and Technologies to Guide Treatm ent Decisions

Keith Robinson, MD, MS, FCCP Clinical Professor Florida International University College of Medicine Miami, FL

Jointly provided by and This educational activity is supported by an educational grant from GlaxoSmithKline.

Agenda

I. Welcome and Introduction

• II. Screening Initiatives and COPD Diagnoses in Early Stages

a) Patient profiles early in disease course b) Lung function decline in mild, moderate, and severe COPD c) Definition of a COPD exacerbation d) Identifying at-risk patients: tools and questionnaires (mMRC and CAT) e) PEF and spirometry: feasibility, necessity, and alternatives

• III. COPD Pocket Consultant Guide: Implementing Evidence-based Recommendations

a) PCG and the COPD Care Algorithm b) COPD severity domains and guideline recommendations c) Pharmacologic escalation and de-escalation strategies: symptoms, severity, and exacerbation risk d) Comparison of different classes and combination of agents

• IV. Facilitating Compliance: New Pharmacologic and Non-pharmacologic Strategies

a) Patient engagement and disease education b) Provider-patient communication tools, mobile app c) Safety and efficacy of new agents d) Comprehensive nonpharmacologic strategies

• V. Question & Answer Session; Post-test and Evaluation

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

The Impact of COPD

• ~15 million people diagnosed (additional 12M are undiagnosed)

– 14% of US population (age 40-79) have COPD – 2nd-leading cause of disability – 3rd-leading cause of 30-day readmissions – 3rd-leading cause of death (2nd to CV disease and cancer)

• Mortality rate predicted to increase by 30% over the next decade
• Exacerbations

– ~800,000 hospitalizations (+ 3.5 million COPD 2nd dx) – 1.5 million ER visits/year

• Costs for COPD in the United States, 2010 = $50 billion and rising
• CDC. Chronic Obstructive Pulmonary Disease. http://www.cdc.gov/copd/.

The COPD Foundation. Chronic Obstructive Pulmonary Disease (COPD). www.copd.org. National Heart, Lung and Blood Institute (NHLBI). COPD – Learn More, Breath Better. https://www.nhlbi.nih.gov/health/educational/copd/index.htm. Guarascio AJ et al. Clinicoecon Outcomes Res. 2013;5:235-245.

Age-standardized Prevalence of COPD

Adults Aged 18 or Older

Han M et al. Lancet Respir Med. 2016;4:473-526.

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

COPD Screening and Diagnosis

CASE 1

52-year-old Woman with Productive Cough and Breathlessness

CASE 1

52-year-old Woman with Productive Cough and Breathlessness

• History of present illness

– Cough x 5 days, yellow sputum and chest congestion after visiting family the prior weekend

• Past medical history

– Hypertension – Similar ‘bronchitis’ episode earlier this year treated with a Z-pack and steroid taper in Urgent care

• Social history

– Works as a beautician – 2 ppd for 30 years

• ROS

– Progressive exertional dyspnea x 10 years

• Physical examination

– Afebrile, RR 22, mild distress, Saturations 98% – Mild forced expiratory wheezing

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Prevalence of COPD Is Higher in Women

Han M et al. Lancet Respir Med. 2016;4:473-526.

Age-adjusted prevalence of self-reported, physician-diagnosed COPD in US (adults aged ≥25 years)

Screening for COPD

Does Spirometry Decrease Morbidity or Mortality?

In asymptomatic patients, the USPSTF does not recommend routine use of spirometry to screen for obstructive lung disease

Asymptomatic Adults No risk factors Smokers,

• ther

exposures Spirometry COPD Medications Pulmonary rehabilitation Oxygen therapy Reduced COPD M/M Harms Harms Vaccines Reduced COPD M/M Reduced COPD M/M Smoking cessation Smoking cessation counseling

Harms

2 1 3 5 6 7 8 4

Guirguis-Blake JM et al. US Preventive Services Task Force Evidence Syntheses. 2016;14-05205-EF-1. M/M = morbidity/mortality; USPSTF = US Preventive Services Task Force

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

High Index of Suspicion for COPD Screening and Diagnosis High Index of Suspicion for COPD Screening and Diagnosis

Pathways for the Diagnosis of COPD

Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. www.goldcopd.org. Used for educational purposes only.

SYMPTOMS

• Shortness of breath
• Chronic cough
• Sputum

RISK FACTORS

• Host factors
• Tobacco
• Occupation
• Indoor/outdoor pollution

SPIROMETRY Required to establish diagnosis

Early Disease: Spiromics

• In patients not meeting current diagnostic criteria for COPD,

50% of current and former smokers had exacerbations, high symptom burden (CAT >10), activity limitation, and evidence of airway disease

• This cohort were current smokers, younger (Mean age <65) and

had a higher body mass index (BMI), chronic bronchitis diagnosis, as well as a history of childhood asthma

Woodruff P et al. N Engl J Med. 2016;374:1811-1821.

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Spiromics

Woodruff P et al. N Engl J Med. 2016;374:1811-1821. Controls Who Never Smoked Current or Former Smokers, FEV1: FVC ≥Specified Cutoff, CAT <10 Current or Former Smokers, FEV1: FVC ≥Specified Cutoff, CAT ≥10 Current or Former Smokers, FEV1: FVC <Specified Cutoff, CAT <10 Current or Former Smokers, FEV1: FVC <Specified Cutoff, CAT ≥10

FEV1: FVC Cutoff to Define Obstruction

0.65 LLN 0.70 0.75 0.6 0.5 0.4 0.3 0.2 0.1 0.0

Patients with Significant Symptoms Have Increased Rate of Exacerbations Regardless of Airflow Obstruction

The Refined ABCD Assessment Tool: GOLD 2017

Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. www.goldcopd.org. Used for educational purposes only.

Spirometrically confirmed diagnosis Assessment of airflow limitation Assessment of symptoms/ risk of exacerbations Post-bronchodilator FEV1/FVC < 0.7

Exacerbation history ≥2 or ≥1 leading to hospital admission 0 or 1 (not leading to hospital admission)

CAT = COPD Assessment Test; FEV1 = forced expiratory volume in one second; FVC = forced vital capacity; mMRC = Modified Medical Research Council

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

GOLD Assessment Tools

Karloh M et al. Chest. 2016;149:413-425.

mMRC Breathlessness Scale

Grade Description of Breathlessness I only get breathless with strenuous exercise 1 I get short of breath when hurrying on level ground

• r walking up a slight hill

2 On level ground, I walk slower than people of the same age because of breathlessness, or have to stop for breath when walking at my own pace 3 I stop for breath after walking about 100 yards or after a few minutes on level ground 4 I am too breathless to leave the house or I am breathless when dressing

COPD Assessment Test (CAT) Rate 0-5 for each item

Score I never cough I cough all the time I have no phlegm (mucus) in my chest at all My chest is completely full of phlegm (mucus) My chest does not feel tight at all My chest feels very tight When I walk up a hill or one flight of stairs I am not breathless When I walk up a hill or one flight of stairs I am very breathless I am not limited doing any activities at home I am very limited doing activities at home I am confident leaving my home despite my condition I am not at all confident leaving my home because of my lung condition I sleep soundly I do not sleep soundly because of my condition I have lots of energy I have no energy at all Total Score:

COPD Assessment(s)

Self-reported Health Status

• COPD Assessment Test (CAT)
• modified Medical Research Council (mMRC)
• Clinical COPD Questionnaire (CCQ)
• St. George’s Respiratory Questionnaire (SGRQ)
• Chronic Respiratory Questionnaire (CRQ)

Karloh M et al. Chest. 2016;149:413-425.

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Yawn BB et al. Chronic Obstr Pulm Dis. 2017;4:177-185.

Spirometry Grades (SG)

SG 0 Normal spirometry does not rule out emphysema, chronic bronchitis, asthma, or risk of developing either exacerbations or COPD SG 1 Mild: Post bronchodilator FEV1/FVC ratio <0.7, FEV1≥60% predicted SG 2 Moderate: Post bronchodilator FEV1/FVC ratio <0.7, 30% ≤FEV1<60% predicted SG 3 Severe: Post bronchodilator FEV1/FVC ratio<0.7, FEV1<30% predicted SG U Undefined: FEV1/FVC ratio ≥0.7, FEV1<80% predicted. This is consistent with restriction, muscle weakness, and other pathologies

FEV1(as % predicted) FEV1/FVC ratio 0.7 100 80 60 40 20

SG 0 SG U SG 3 SG 2 SG 1

Obstruction Present

Severity Domains

2017 Update to the COPD Foundation COPD Pocket Consultant Guide

Severity Domains

2017 Update to the COPD Foundation COPD Pocket Consultant Guide

Barriers to Diagnosing COPD in the Primary Care Setting Barriers to Diagnosing COPD in the Primary Care Setting

Russell D et al. Curr Opin Pulm Med. 2016;22:91-99.

Care Providers Time limitations

Failure to probe at-risk patients about symptoms and activity levels, and lack of good case- finding methods Limited spirometry availability and expertise to interpret results

Patients

Under-recognition of symptoms, leading to delayed presentation Poor awareness

• f COPD

Lack of knowledge regarding COPD risk factors and appropriate diagnostic testing

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Alternatives to Spirometry to Identify At-risk Patients

• Peak Expiratory Force (PEF), FEV1/FEV6 monitoring device

– Significantly correlates with spirometric values (FEV1), FEV/FVC ratio, percent predicted, and GOLD categories (ABCD)

• Questionnaires

– Capture, COPD-PS, COPD Diagnosis Questionnaire (CDQ), and Differential Diagnosis Questionnaire (DDQ)

• Combination of PEF and Questionnaire

– Capture + PEF

Press VG et al. JAMA. 2017;318:1702-1703.

Peak Expiratory Flow

• Advantages

– Simple to use – Less time to perform – Can be performed daily

• Disadvantages

– Not able to detect sudden changes in COPD – Cannot be used as a surrogate for FEV1 – does not find mild COPD – Does not determine the severity of airflow limitation (obstruction)

Bhowmik A. NPJ Prim Care Respir Med. 2017;27:32..

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Identifying Undiagnosed COPD: CAPTURE

Martinez F et al. Am J Resp Crit Care Med. 2017;95:748-756.

• This five-item questionnaire is used to assess exposure, breathing problems, tiring easily, and acute respiratory

illnesses, as well as identifying patients in need of further diagnostic evaluation for COPD

• In these patients, the addition of PEF can be useful for identifying patients in need of further diagnostic evaluation

for COPD (score 3 or 4)

• Patients that answer yes to all items (score of 5 or 6) are considered to have a high likelihood of symptomatic lung

disease and increased exacerbation risk

– These patients should be referred for further evaluation by spirometry

• Low scores (1 or 2) do not warrant more testing

Please answer each question No Yes

• 1. Have you ever lived or worked in a place with dirty or polluted air, smoke, second-hand smoke, or dust?
• 2. Does your breathing change with seasons, weather, or air quality?
• 3. Does your breathing make it difficult to do things such as carry heavy loads, shovel dirt or snow, jog, play tennis, or swim?
• 4. Compared to others your age, do you tire easily?

1 2 or more

• 5. In the past 12 months, how many times did you miss work, school, or other activities due to a cold, bronchitis, or pneumonia?

PEF + Capture Significantly Identifies COPD in Primary Care: ROC Curves for Comparisons

Martinez F et al. Am J Resp Crit Care Med. 2017;95:748-756.

1.00 0.75 0.50 0.25 0.00 Sensitivity 0.00 0.25 0.50 0.75 1.00 1 - Specificity

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

COPD Exacerbations

COPD Exacerbations

• Major criteria include: Dyspnea, sputum volume, and/ or color/purulence
• Minor criteria include: wheeze, cough, sore throat, and fever
• An abrupt change in the day to day variability of symptoms: cough frequency,

congestion, sputum production, and dyspnea for 2 consecutive days – However, there is no universally accepted standard definition of an acute exacerbation

• Infections cause ~75% of exacerbations: 25% bacterial, 25% viral, and 25% both
• Allergen and environmental pollutants account the the remainder of causes
• Exacerbations are characterized by increased systemic and airway inflammation

Markis D et al. BMC Pulm Med. 2009;9:6. Rabe KF et al. Am J Respir Crit Care Med. 2007;176:532-555.

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Exacerbation Definitions

• Mild COPD Exacerbation: a change in inhaled medications
• Moderate COPD Exacerbation: office visit or urgent care visit

leading to steroid use, antibiotic use or both

• Severe COPD Exacerbation: emergency department stay or

inpatient hospitalization

Oliveira AS et al. Pulmonology. 2018;24:42-47.

Instead of biomarkers of disease activity, the search for the ability to adapt and self manage after an AECOPD may be the key toward lowering the impact of exacerbation on disease progression. #1: Early Recovery #2: Late Recovery #3: Defect in Recovery #4: Degree of Stress #5: Time to Recovery #6: Ideal state of Recovery Instead of biomarkers of disease activity, the search for the ability to adapt and self manage after an AECOPD may be the key toward lowering the impact of exacerbation on disease progression. #1: Early Recovery #2: Late Recovery #3: Defect in Recovery #4: Degree of Stress #5: Time to Recovery #6: Ideal state of Recovery

Spruit M et al. Eur Respir J. 2016;47:1024-1027.

Impact of a COPD Exacerbation: Hypothetical Trajectories

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

COPD Foundation Pocket Guide Algorithm

Yawn BB et al. Chronic Obstr Pulm Dis. 2017;4:177-185.

COPD is defined by post bronchodilator FEV1/FVC ratio <0.7 on spirometry All COPD patients should have smoking cessation if smoking, vaccinations and be on a regular exercise program Symptoms (CAT or MMRC) and Exacerbations MMRC 0, 1 CAT < 10 Exacerbations <2/year MMRC ≥2, CAT ≥10 With or without exacerbations MMRC 0,1 CAT<10 Exacerbations ≥2/year prn SABD LAMA or LAMA + LABA plus Pulmonary Rehabilitation LAMA or LAMA + LABA

• r LABA + ICS

Persistent Symptoms LAMA LAMA + LABA + ICS Persistent Symptoms or Exacerbations Assessment Treatment Instrument or metric

Implementing Evidence-based Recommendations

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

• Age: 62
• Occasional cough, no sputum
• Diagnosed with COPD; 2 years with spirometry
• Ex-smoker; smoking history: 35 pack-years
• He is married with 2 children and works as a mail carrier
• No exacerbations
• Has hypertension, controlled with medication
• The patient is taking a LABA+ICS maintenance medication for COPD but frequently

uses rescue inhaler 3 to 4 times per day

• When asked, he says he sometimes has to sit down to rest while delivering mail
• He also added that lately he is unable to play ball with his grandkids
• MMRC=2, CAT=12

Case: Charles

• FEV1: 1.31 (45%)
• FVC: 2.48 (76%)
• Ratio: 0.53

Pharmacologic Treatment Paradigm

Pharmacologic Treatment Algorithms by GOLD

Pharmacologic Treatment Paradigm

Pharmacologic Treatment Algorithms by GOLD

Vogelmeier CF et al. Am J Respir Crit Care Med. 2017;195:557-582. = preferred treatment

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Pharmacologic Options

Bronchodilators

SHORT-ACTING LONG-ACTING

Anticholinergic (SAMA) Ipratropium Anticholinergic Tiotropium Aclidinium Umeclidinium Glycopyrrolate Beta2-agonists (SABA) Albuterol Levalbuterol Metaproterenol Pirbuterol Beta2-agonists (LABA) Salmeterol Formoterol Arformoterol Indacaterol (ultra) SAMA + SABA Ipratropium + albuterol LAMA + LABA Umeclidinium + vilanterol Tiotropium + olodaterol Glycopyrrolate + formoterol Glycopyrrolate + indacaterol Theophylline

Anti-inflammatory

ICS + LABA Fluticasone + salmeterol Budesonide + formoterol Fluticasone + vilanterol PDE-4 inhibitors Roflumilast Oral steroids Prednisone Methylprednisone

Vogelmeier CF et al. Am J Respir Crit Care Med. 2017;195:557-582.

LAMA

UPLIFT

• 4-year trial to determine the long-term benefits of tiotropium on mortality,

safety, exacerbations, and hospitalizations

• Delayed time to first exacerbation by 4 months
• Reduced exacerbations per patient per year by 14%
• Reduced risk of hospitalizations due to exacerbations
• Improved quality of life
• Reduced mortality due to heart or lung disease
• Post-hoc analysis demonstrates exercise capacity benefit in patients with mild

to severe COPD

Tashkin D et al. N Engl J Med. 2008;359:1543-1554.

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

LABA

• Sustained bronchodilation without tolerance, improving airflow

limitation >12 hours

• Maintenance therapy for patients with moderate to very severe COPD
• Improved lung function
• Reduced breathlessness
• Reduced exacerbations in patients with moderate to severe COPD
• Improved health status in patients with COPD

Wang J et al. J Clin Pharm Ther. 2012;37:204-211.

LABA/LAMA

FLAME/LANTERN/FLIGHT

• First-line therapy in moderate to severe COPD
• Significantly reduced COPD exacerbations
• Significantly improved lung function, dyspnea, and quality of life
• Significantly reduced rescue inhaler use
• Significantly reduced the risk of pneumonia compared to ICS

containing inhaled therapy

• All combinations on market have similar cost-effectiveness ratios

Wedzicha JA et al. N Engl J Med. 2016;374:2222-2234. Lopez-Campos JL et al. Int J Chron Obstruct Pulmon Dis. 2017;12:1867-1876.

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

LABA/ICS

TORCH

• Ambitious 3-year, randomized trial to determine the effects of combination

therapy fluticasone propionate/salmeterol 500/50 mcg BID on mortality, COPD exacerbations, hospitalizations, and quality of life in patients with moderate to severe COPD

• No mortality benefit, but…

– Statistics trends toward benefit, as many in placebo left trial

• Decreased exacerbations by 25%, producing NNT=4 to prevent one

exacerbation

• Decreased hospitalizations by 17%, but…

– 49% increased risk of pneumonia, producing NNH=17

Calverley PM et al. N Engl J Med. 2007;356:775-789.

Fixed LAMA/LABA Combinations

Drug Approved Dose Approval Status Umeclidinium/vilanterol 62.5/25 μg once daily (USA) 55/22 μg once daily (Europe) FDA approved 2013. EMA positive opinion 2014. Indacaterol/glycopyrronium (QVA149) 110/50 μg once daily –Europe, Canada, Japan, Latin America EMA positive opinion 2013, FDA application complete for 27.5/12.5 μg twice daily. Aclidinium/formoterol 340/12 μg twice daily EMA positive opinion 2014 Tiotropium/olodaterol 2.5/2.5 μg two puffs once daily FDA approved 2015. Glycopyrronium/formoterol 9/4.8 μg two puffs twice daily MDI format Pearl Pharmaceuticals

Lal C et al. Expert Opin Pharmacother. 2017;18:1833-1843.

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

LABA/LAMA

• LABA/LAMA was superior to LABA/ICS in terms
• f annual rate and time to first exacerbation

Wedzicha JA et al. N Engl J Med. 2016,374:2222-2234.

If Initial Treatment Is Not Effective, Re-evaluate the Situation If Initial Treatment Is Not Effective, Re-evaluate the Situation

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Phosphodiesterase 4 (PDE-4) Inhibitors

Roflumilast

• First studied in 2005 and FDA-approved in 2009, the PDE-4 class

demonstrates improved quality of life, lung function, and exacerbations

• PDE-4 is novel anti-inflammatory that decreases epithelial cell apoptosis, via

increasing cAMP, thus decreasing macrophage activity and neutrophil recruitment

• Effective in inflammatory endotypes, like chronic bronchitis
• Indicated for patients with COPD exacerbation history
• Significantly decreases the frequency of exacerbations
• GI side effects and weight loss have limited wide spread use

Calverley PM et al. Lancet. 2009;374:685-694. Martinez F et al. Lancet. 2015;385:857-866. Wedzicha JA et al. Int J Chron Obstruct Pulmon Dis. 2016;11:81-90.

Matching the Patient With the Delivery Device

When choosing a delivery device assess patients for:

• Cognition

– Dementia – Health literacy

• Dexterity

– Hand grip strength – Arthritis – Breathe hand coordination

• Peak Inspiratory Flow Rate (PIFR)

– Stature – Sex

Improper use has been associated with:

• Older age
• Lower education level (low

health literacy)

• Lack of instruction from

healthcare providers

Melani AS et al. Respir Med. 2011;105:930-938.

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Facilitating Compliance

New Pharmacologic and Non-pharmacologic Strategies Individualizing Inhaled Therapy

• Good hand-breath coordination is required for meter-dose

inhalers (MDIs)

– May not be suitable for elderly, confused, or those with hand conditions (e.g. arthritis)

• Dry-powder inhalers (DPIs) do not require coordination of

actuation and inhalation and are easier to use than MDIs

– Breath actuation may be difficult in patients with poor inspiratory effort

• Nebulizers require cleaning and assembly

– May require the skills of a caregiver

Vincken W et al. Prim Care Respir. 2010;19:10-20. De Coster DA, Jones M. Curr Respir Care Rep. 2014;3:121-132.

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Ghosh S et al. J Aerosol Med Pulmn Drug Deliv. 2017;30:381-387.

Some with High and Some with Low Resistance – Choice Is Important Some with High and Some with Low Resistance – Choice Is Important

• Peak inspiratory flow rate
• Measured in L/min
• PIF measured using the In

Check Dial device

– Good accuracy +/- 10L/min, test-retest reliability

When choosing a delivery device, assess PIFR:

Hanania NA et al. Chronic Obstr Pulm Dis. 2018;5:111-123.

Non-pharmacologic Strategies Non-pharmacologic Strategies

Smoking Cessation Pulmonary Rehabilitation Vaccination Oxygen Therapy Surgical Nonsurgical Alternatives

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Smoking Cessation Reduces Mortality

Anthonisen NR et al. Ann Intern Med. 2005;142:233-239. Sustained quitter Intermittent quitter Continuing smoker

4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0

CHD CVD Lung cancer Other cancer Respiratory disease Other Unknown

Cause of Death Rate of Death per 1,000 Person-Years

Adapted (and improved) from the BTS Statement: Pulmonary Rehabilitation.

• Thorax. 2001;56:827-834.

Components of Pulmonary Rehabilitation

• Education, especially self-management training
• Physical exercise training
• Psychosocial intervention
• Nutrition assessment and intervention
• Outcome assessment

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Pulmonary Rehabilitation

Improves Exercise and Quality of Life at 1 Year

Pulmonary Rehabilitation

Improves Exercise and Quality of Life at 1 Year

SGRQ = St. George’s respiratory questionnaire Adapted from Griffiths TL et al. Lancet. 2000;355:362-368.

P = .002 Distance Walked (Meters) 1 Year 100 175 212 137 6 Weeks Before P = .000

Exercise

Rehab Control QoL (SGRQ Total Score) 1 Year 6 Weeks Before 50 62 69 56 P = .000 P = .010 Rehab Control

Quality of Life (QoL)

Improved COPD Survival on Long-term Oxygen Treatment

Güell Rous R. Int J Chron Obstruct Pulmon Dis. 2008;3(2):231-237. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93(3):391-398. Medical Research Council Working Party. Lancet. 1981;1(8222):681-686. NIH-COT MRC-02 NIH-NOT MRC controls

100 90 80 70 60 50 40 30 20 10 10 20 30 40 50 60 70

Time (months) Cumulative Survival (%)

NIH-COT, National Institute

• f Health-Continuous

Oxygen Therapy MRC, Medical Research Council NIH-NOT, National Institute

• f Health-Nocturnal Oxygen

Therapy

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Vaccines

• RCT comparing injectable pneumococcal polysaccharide vaccine or

pneumococcal conjugated vaccine in people with COPD – reduced COPD exacerbation (OR 0.60, 95% CI 0.39 to 0.93)

– Number Needed to Benefit (NNTB) to prevent a patient from experiencing an acute exacerbation was 8 (95% CI 5 to 58)1

• Inactivated influenza vaccine in COPD patients resulted in a significant

reduction in the total number of exacerbations per vaccinated subject compared with those who received placebo (weighted mean difference [WMD] -0.37, 95% confidence interval -0.64 to -0.11, P=0.006)2

1Walters JA et al. Cochrane Database Syst Rev. 2017;1:CD001390. 2Poole PJ et al. Cochrane Database Syst Rev. 2006;(1):CD00273.

Upper Lobe Disease and Poor Exercise Function

• 1218 patients with severe COPD
• Rehabilitation
• Assess

– CT distribution – Exercise performance

• Randomize

– Surgery – Medical management

• Re-evaluate 6 months, yearly
• Assess

– Survival – Exercise

Fishman A et al. N Engl J Med. 2003;348:2059-2073.

Volume Reduction Surgery in Chronic Obstructive Pulmonary Disease: NETT Trial

Probability of Death Months after Randomization

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Ideal COPD Treatment Team

• Comprise a COPD Treatment Team to approach the proper care and treatment of the patient:

– Patient; Support person (family member or caregiver); PCP; Specialists

• The COPD Treatment Team should formulate an action plan to address specific issues that the

patient may encounter.

• Specific instructions should accompany the action plan and be signed off on by all parties.
• Biennially, the COPD Treatment Team should update the action plan and their individual roles
• If properly carried out, this action time will save time and ultimately improve patient outcomes
• Technology can play a huge role in reducing the workload of sharing and transmitting

information

• Example apps for patients with COPD:

– Medisafe, ZocDoc

https://lungdiseasenews.com/2018/01/23/7-best-apps-chronic-illness-management-2.

COPD Patient Care Considerations

• Avoid rushing or appearing to rush through

a visit.

• Avoid over-estimating your knowledge and
• competence. Seek a pulmonology consult.
• Avoid casting judgement about how the

person got this disease – this patient has a chronic illness.

• Avoid allowing patients to become

complacent in their treatment. Demand that they play an active role in care.

• Answer all of the questions that the patient

has.

• Give the patient a folder with information

related to his/her diagnosis and treatment. Request that the patient read over the materials and make at least one contact.

• Provide contacts for local support groups
• Impress upon the patient that prompt

medical attention is necessary to avoid major problems.

• Make same-day appointments available for

your COPD patients.

Assessment and Management of COPD Patients in Primary Care Tools and Technologies to Guide Treatment Decisions MEDX Atlanta – September 29, 2018

Summary

• COPD is a costly, prevalent disease that should be screened in patients with risk

factors and with symptoms suggestive of airflow obstruction

• Recognition of the many endotypes of COPD has not only improved maintenance

management, but has also led to the development of therapies that decrease exacerbations and improve QoL, as well as exercise capacity

• GOLD 2017 recommendations support use of long-acting maintenance treatment in

patients with high symptom burden and/or history of COPD exacerbation

• Non-pharmacologic management of COPD entails early referral to pulmonary

rehabilitation, smoking cessation, and augmenting self-efficacy to remain physically active regardless of disease severity

• Primary care providers can initiate many strategies to ensure adherence to COPD

therapies and to increase patient understanding

Thank you for joining us today! Please rem em ber to com plete the EVALUATI ON. Your participation w ill help shape future CME activities.

Assessm ent and Managem ent of COPD Patients in Prim ary Care: Tools and Technologies to Guide Treatm ent Decisions