Blue, Pink and everything in between: an update on COPD Tara - - PowerPoint PPT Presentation

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Blue, Pink and everything in between: an update on COPD Tara - - PowerPoint PPT Presentation

Mar 09, 2023 440 likes •805 views

Blue, Pink and everything in between: an update on COPD Tara Lohmann MD FRCPC Division of Respirology University of Calgary Disclosures I have eaten lunches provided by many pharmaceutical companies (GSK, Boeringer-Ingleheim,

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Blue, Pink and everything in between: an update

  • n COPD

Tara Lohmann MD FRCPC Division of Respirology University of Calgary

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Disclosures

  • I have eaten lunches provided by many pharmaceutical companies

(GSK, Boeringer-Ingleheim, AstraZeneca, Novartis)

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Outline

  • 1. Highlights of the 2017 COPD statements
  • What’s with inhaled corticosteroids in COPD?
  • Inhaler review
  • 2. Update on smoking cessation
  • 3. INSPIREDTM to reduce hospitalizations in COPD
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John

  • 71 year old retired carpenter
  • Presents to your clinic with slowly progressive

dyspnea  mMRC4

  • Known COPD (FEV1 47%).
  • 3 Hospitalizations for AECOPD in the past year
  • Smokes 1 ppd (60 pack-year Hx)
  • COPD Meds:

▫ Tiotropium 18ug daily (LAMA) ▫ Salbutamol prn (SABA)

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NEJM 2014: 371; 4

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What patient category is John in?

  • a. A
  • b. B
  • c. C
  • d. D
  • e. Huh?
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Vogelmeier et al. AJRCCM 2017

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Vogelmeier et al. AJRCCM 2017

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www.catestonline.org

COPD Assessment Test (CAT)

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Gruffydd-Jones K Prim Care Respir J 2012; 21:437-441

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What will you do with his inhalers?

a) Add LABA (dual bronchodilator therapy) b) Add LABA/ICS combination (triple therapy) c)

Tell him the inhalers won’t help him; he can stop them

d) Add ipratropium (SAMA) prn e) No change

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Bourbeau et al. Canadian Journal sleep, critical care, sleep medicine 2017

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When do you add inhaled corticosteroids (ICS)?

a) Not needed for this patient: He doesn’t have asthma b) If he continues to exacerbate despite LAMA/LABA c) When the IM resident tells you to d) Always. More is better in COPD

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Risks of Inhaled Corticosteroids (ICS)

  • Pneumonia (OR 2.0)

 Elderly  BMI >25  More severe airflow obstruction

  • Non-tuberculous mycobacteria (OR 2.51)
  • Osteoporosis
  • Cataracts
  • Glaucoma

Ernst et al. ERJ 2015; 45: 525-537 Yiu et al. Annals ATS 2018

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Magnussen et al. NEJM 2014

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Lipson et al. NEJM 2018; 378 (18)

Is triple therapy more effective at reducing exacerbations than dual therapy?

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IMPACT trial results

Lipson et al. NEJM 2018; 378 (18)

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Bottom line for ICS in COPD

  • ICS should NOT be used as monotherapy in COPD
  • Consider ICS in addition to LAMA/LABA for those with moderate-

severe COPD and frequent exacerbations

  • ICS may benefit those with peripheral eosinophilia (2-4% or >=300

cell/uL) OR sputum eosinophilia (>3%) OR an Asthma-COPD phenotype

  • Withdrawal of ICS in COPD is likely safe

Bourbeau et al. Canadian Journal sleep, critical care, sleep medicine 2017

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Inhaler update

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What’s new in Smoking cessation

  • Very brief intervention (A’s)
  • Nicotine replacement plus

varenicline

  • E-cigarettes
  • Smartphone technology

Hartmann-Boyce et al. Cochrane Database of Systematic reviews 2016

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What you do matters!

  • Inpatients

 19% of inpts who had a smoking cessation intervention had remained abstinent 6 months post discharge (BMJ

2013)

  • Pre-operative clinic

 Smoking quit rates pre-operatively are higher than for patients who quit for general health reasons (Thorac

Surg Clin 2012)

 Recent data suggests quitting within 2-4 weeks of surgery doesn't have worse outcomes (Systematic review J

anesth 2013)

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AAR: If time is of the essence

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  • JAMA. 2014;312(2):155-161. doi:10.1001/jama.2014.7195
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  • JAMA. 2014;312(2):155-161. doi:10.1001/jama.2014.7195
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E-cigarettes: Jury is still out

  • E-cigarettes with nicotine likely

more effective than E-cig alone

  • Fewer toxicants than cigarettes

(Tob Con 2014)

  • Still no proof of longterm safety

 May alter gene expresstion (Clin Cancer Res 2014)  May be toxic to alveolar macrophages (Thorax 2018)

  • Nicotine in E-cigarettes soon to

be legal in Canada

McRobbie et al. Cochrane syst rev 2014; 12 Middlekauf Chest 2015

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Smoking Cessation Apps

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How to reduce John’s readmissions?

  • Pulmonary rehabilitation (< 4 weeks of

AECOPD) (1C)

  • Written action plan + case management

(2B) - INSPIRED

  • Pharmacologic therapies

Criner et al. CHEST 2015

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INSPIRED COPD Outreach Program TM

Rocker, G.M. & Verma, J. ‘INSPIRED’ COPD Outreach Program™: Doing the right things right. Clinical & Investigative Medicine 2014; 38(1): E311-E319.

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http://www.copdactionplan.com/CTS_COPD_updated_Action_Plan_editable_PDF_2013.pdf

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Outline

  • 1. Highlights of the 2017 COPD guidelines
  • What’s with inhaled corticosteroids in COPD?
  • Inhaler review
  • 2. Update on smoking cessation
  • 3. INSPIREDTM and other ways to reduce hospitalizations

in COPD

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Thank you!

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Resources

https://www.canada.ca/en/health-canada/services/canadian-tobacco- alcohol-drugs-survey.html https://www.albertaquits.ca/ https://www.livingwellwithcopd.com/3-39-user-tool-how-to-use-my- inhaler-properly-.html www.resptrec.org