Management of COPD Updates and Evidence Providence Alaska Medical - - PowerPoint PPT Presentation

Management of COPD Updates and Evidence

Providence Alaska Medical Center PGY1 Pharmacy Practice Residents Ann-Chee Cheng, PharmD Kaite Kammers, PharmD

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Disclosures

• All presenters of this activity have no financial relationships relevant to this activity

Objectives

• 1. Describe the updated recommendations in the Global Initiative for

Chronic Obstructive Lung Disease (GOLD) 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD

• 2. Compare and contrast therapies for management of COPD based on

evidence from recent clinical trials

• 3. Develop a management plan for COPD using 2017 GOLD guidelines

Pre-Test

1. Which inhaled medication is no longer a preferred agent in the management of COPD? 2. Which inhaled medication(s) is now emphasized/ preferred in all ABCD severity groups? 3. What class of medications was added to step-up therapy for an exacerbation in a group D patient? 4. What are goals of treatment for improving inhaler technique? 5. Based on results from the FLAME study, which combination of inhaled medications lengthened time between exacerbations? 6. What did the results of the WISDOM study show in relation to withdrawing ICS from patients on triple therapy? 7. What population(s) was shown to benefit most from adding roflumilast to maintenance therapy? 8. What should be assessed in regard to medication use in all patients prior to escalating therapy in COPD?

COPD Death Rates in the United States

Thun MJ, Carter BD, Feskanich D, et al. 50-year trends in smoking-related mortality in the United States. N Engl J Med. 2013;368(4):351-64.

Revisions to the GOLD Guidelines

• Updated the definition of COPD
• Separated GOLD category from COPD severity group
• Added long-acting muscarinic antagonist (LAMA) and long-acting

beta2 agonist (LABA) to mild COPD patients

• Removed inhaled corticosteroids (ICS) as preferred agents in the group

C and D

• Added azithromycin and erythromycin as alternative agents
• Emphasized inhaler technique teaching

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

Definition of COPD

• Common, preventable, and treatable pulmonary disease
• Persistent respiratory symptoms and airflow limitation due to airway

and/or alveolar abnormalities

• Usually caused by interaction of significant exposure to noxious

particles gases and specific host factors

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

Question 1:

Which of the following GOLD grades and severity groups are appropriate for a 65- year old with COPD Assessment Test (CAT) score of 28 today, not COPD exacerbations in the past year and forced expiratory volume in 1 second (FEV1) of 29% of the predicted value 1 month ago?

• A. GOLD grade 4, group B
• B. GOLD grade 4, group D
• C. GOLD grade 1, group A
• D. GOLD grade 1, group C

Severity of Airflow Limitation - GOLD Grades

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

2016 GOLD Guidelines Severity

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2016. www.goldcopd.org.

2017 GOLD Guidelines Severity

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

COPD Assessment based on GOLD 2017

• 1. Use Spirometry to diagnose COPD and assess airflow limitation

(GOLD grade)

• 2. Use CAT or mMRC to assess COPD symptom severity
• 3. Determine exacerbation risk:
• a. Number of COPD exacerbations in past 12 months
• b. Number of COPD-related hospitalizations in the past year

Question 2:

Which of the following types of medications are currently recommended for a 45-year old with

• ne COPD-related hospitalization in the past year, a CAT score of 28 and a FEV1 49% and the

predicted value with no airway reversibility who is using an albuterol metered-dose inhaler (MDI) 90 mcg 2 puffs 3 - 4 times/ day for COPD symptoms? A. Tiotropium/ Olodaterol B. Budesonide/ Formoterol C. Fluticasone/ Umeclidinium/Vilanterol D. Ipratropium/ Albuterol

2016 GOLD: Initial Medications

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2016. www.goldcopd.org.

2017 GOLD: Initial Medications

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

Question 3:

Which of the following step-up options is recommended for a 75-year old woman with GOLD grade 4, group D COPD currently taking ICS/LABA and a LAMA? She is adherent to her inhalers and is able to use them correctly. She is on 2L of oxygen/ 24 hours. She continues to have a CAT score of 30 and a COPD exacerbation every other month. Despite quitting smoking 1 year ago, she is losing weight and complains of feeling depressed. A. Azithromycin B. Roflumilast C. Theophylline D. Prednisone

Step-up / Alternative Medications

2016

• LAMA and/or LABA and/or ICS

combinations

• SAMA + SABA
• Theophylline
• Roflumilast + LAMA
• Roflumilast + LABA
• ICS + LABA + roflumilast

2017

• LAMA and/or LABA combination
• LABA + ICS
• LAMA + LABA + ICS
• Step-up:

○ Roflumilast ○ Azithromycin ○ Erythromycin

• Other:

○ ICS withdrawal?

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

Azithromycin and Erythromycin

• Decreased exacerbations when used for 6 -12 months
• No significant decrease in hospitalizations or overall mortality
• Increased side-effects
• Unknowns:

○ Optimal dosing ○ Duration of therapy (no data past 12 months) ○ Subpopulations with the most benefit

Ni W, Shao X, Cai X, et al. Prophylactic use of macrolide antibiotics for the prevention of chronic obstructive pulmonary disease exacerbation: a meta-analysis. PLoS ONE. 2015;10(3):e0121257.

ICS Withdrawal

• Mixed data on if w/d increases lung function and/or decreases

exacerbations

• Background use of LAMA or LABA may minimize effect
• Modest decrease in FEV1 (~ 40mL)

Magnussen H, Disse B, Rodriguez-roisin R, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med. 2014;371(14):1285-94. Watz H, Tetzlaff K, Wouters EF, et al. Blood eosinophil count and exacerbations in severe chronic obstructive pulmonary disease after withdrawal of inhaled corticosteroids: a post-hoc analysis of the WISDOM trial. Lancet Respir Med. 2016;4(5):390-8.

Triple Inhaled Therapy

• LABA + LAMA + ICS = triple inhaled therapy

○ Fluticasone furoate + umeclidinium + vilanterol 100 mcg/62.5 mcg/ 25 mcg (Trelegy Ellipta™) daily -- approved September 2017

• Add LAMA to existing LABA/ICS regimen improves lung function and patient

reported exacerbations

• Single study found no benefit of adding ICS to LABA/LAMA combination
• More evidence needed if triple inhaled therapy is more beneficial than

LABA/LAMA alone

Brusselle G, Price D, Gruffydd-jones K, et al. The inevitable drift to triple therapy in COPD: an analysis of prescribing pathways in the UK. Int J Chron Obstruct Pulmon Dis. 2015;10:2207-17. Aaron SD, Vandemheen KL, Fergusson D, et al. Tiotropium in combination with placebo, salmeterol, or fluticasone-salmeterol for treatment of chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2007;146(8):545-55.

Question 4:

A 55-year old with COPD returns to clinic with questions about the proper use of his Respimat inhaler. Which of the following techniques is correct for the use of this inhaler?

• A. Priming the inhaler before the first use
• B. Opening the cap and then twisting the base
• C. Placing the mouthpiece 2 finger spaces away from the mouth
• D. Inhaling use a quick and steady breath

Critical Errors with Inhalers

Van der palen J, Thomas M, Chrystyn H, et al. A randomised open-label cross-over study of inhaler errors, preference and time to achieve correct inhaler use in patients with COPD or asthma: comparison of ELLIPTA with other inhaler devices. NPJ Prim Care Respir Med. 2016;26:16079.

Question 5:

A COPD patient reports a history of intolerance to propellants in inhalers. Which of the following inhalation delivery systems uses a propellant?

• A. Metered-dose inhaler
• B. Dry powder inhaler
• C. Jet nebulizer
• D. Propellants are no longer used inhalation devices

Goals of Treatment with Inhaler Emphasis

• Reduce risk
• Reduce symptoms
• Personalized
• Inhaler improvement:

○ Facilitate drug deliver ○ Reduce frequency ○ Minimize number of inhalers ○ Still the same drug classes….

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of COPD 2017. www.goldcopd.org.

Procalcitonin

• Procalcitonin guided antibiotics associated with decreased antibiotic

exposure without affecting clinical outcomes (Evidence: Low- Moderate)

• Specific for bacterial infections

○ Rule out patients who may not benefit from antibiotics during exacerbations

Christ-crain M, Jaccard-stolz D, Bingisser R, et al. Effect of procalcitonin-guided treatment on antibiotic use and outcome in lower respiratory tract infections: cluster-randomised, single-blinded intervention trial. Lancet. 2004;363(9409):600-7. Schuetz P, Christ-crain M, Thomann R, et al. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA. 2009;302(10):1059-66.

Recently Published Evidence

• FULFIL - 2017
• FLAME - 2016
• WISDOM - 2014
• RE2SPOND - 2016
• Tie-COPD - 2017

Question 6:

How are COPD exacerbations classified per GOLD guidelines?

• Mild
• Moderate
• Severe

True or False:

• FEV1 is a good marker to determine likelihood of exacerbation risk

Question 6:

How are COPD exacerbations classified per GOLD guidelines?

• Mild -

can be treated with short acting bronchodilators (SABD)

• Moderate -

treated with SABD + antibiotics + PO corticosteroids

• Severe -

requires hospitalization or ER visit True or False:

• FEV1 is a good marker to determine likelihood of exacerbation risk - False

FULFIL Study - 2017

Study comparing once a day triple agent therapy in a single inhaler with two agent twice a day therapy in a single inhaler for those at high risk of exacerbations

• 24 week randomized control trial double blind and double dummy

Fluticasone 100 mcg + Umeclidinium 62.5 mcg + Vilanterol 25 mcg

VS

Budesonide 400 mcg + Formoterol 12 mcg (ICS + LAMA + LABA) once daily (ICS + LABA) twice daily

Lipson DA, Barnacle H, Birk R, et al. FULFIL Trial: Once-Daily Triple Therapy for Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2017;196(4):438-446.

FULFIL Study Population

• n = 1810
• 64 year old males (74%)
• Current or past average 39 pack year smoking history
• Average FEV1 = 49% predicted (~ GOLD 3)
• About 65% experienced > 1 moderate or severe exacerbation in the

previous year

Lipson DA, Barnacle H, Birk R, et al. FULFIL Trial: Once-Daily Triple Therapy for Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2017;196(4):438-446.

FULFIL Design & Results

Outcomes ITT LAMA + LABA + ICS LABA + ICS P value Primary Mean change in FEV1 from baseline + 142 mL

• 29 mL

<0.001 Mean change in SGRQ from baseline

• 6.6 units
• 4.3 units

<0.001 Secondary Rate of mild, moderate & severe exacerbations Addition of LAMA to LABA + ICS therapy reduced rate by 35% ADE Pneumonia 20/911 (2.2%) 7/899 (0.8%)

Lipson DA, Barnacle H, Birk R, et al. FULFIL Trial: Once-Daily Triple Therapy for Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2017;196(4):438-446.

Mean Change in FEV1 from Baseline

Lipson DA, Barnacle H, Birk R, et al. FULFIL Trial: Once-Daily Triple Therapy for Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2017;196(4):438-446.

Baseline

FULFIL Study Discussion

• Contributes to current evidence that has already shown adding LAMA

to LABA + ICS results in improvement in lung function and QoL

• This product likely provides benefit in regards to patient adherence
• Funded by GSK, makers of Trelegy ElliptaTM inhaler
• Did not report pre-enrollment COPD maintenance regimens
• Improvement of FEV1 has questionable clinical significance

Frith PA, et al. Glycopyrronium once-daily significantly improves lung function and health status when combined with salmeterol/fluticasone in patients with COPD: the GLISTEN study, a randomized controlled trial. Thorax 2015; 70(6): 519-27. Singh D, Papi A, Corradi M, et al. Single inhaler triple therapy versus inhaled corticosteroid plus long-acting β2-agonist therapy for chronic

• bstructive pulmonary disease (TRILOGY): a double-blind, parallel group, randomised controlled trial. Lancet. 2016;388(10048):963-73.

FLAME Study - 2016

A study comparing exacerbation rate for dual long acting bronchodilator therapy with the standard of care (LABA + ICS) for those with severe COPD

• 52 week RCT double blind, double dummy, non-inferiority trial (HR margin

15%)

Indacaterol 110 mcg + Glycopyrronium 50 mcg

VS

Salmeterol 50 mcg + Fluticasone 500 mcg (LAMA + LABA) once daily (LABA + ICS) twice daily

Wedzicha JA, Banerji D, Chapman KR, et al. Indacaterol-Glycopyrronium versus Salmeterol-Fluticasone for COPD. N Engl J Med. 2016;

FLAME Study Population

• n = 3362
• ~ 65 year old males (76%)
• Generally diagnosed COPD for 7.3 yrs and Group D at time of study

(74.8%)

• Average FEV1 = 44.1% predicted

Wedzicha JA, Banerji D, Chapman KR, et al. Indacaterol-Glycopyrronium versus Salmeterol-Fluticasone for COPD. N Engl J Med. 2016;

FLAME Design & Methods

Outcomes ITT LAMA + LABA LABA + ICS Rate ratio Primary Annual rate of any exacerbation 3.59 4.03 0.89 (11% lower) p = 0.003 LAMA + LABA was non-inferior to LABA + ICS for decreasing annual rate of any COPD exacerbation Secondary Time to 1st exacerbation

• f any severity

71 days 51 days 0.84 (16% lower) p < 0.001 Annual rate mod/severe exacerbation 0.98 1.19% 0.83 (17% lower) p < 0.001 Time to 1st mod/severe exacerbation 127 days 87 days 0.78 (22% lower) p < 0.001

Wedzicha JA, Banerji D, Chapman KR, et al. Indacaterol-Glycopyrronium versus Salmeterol-Fluticasone for COPD. N Engl J Med. 2016;

FLAME Results

Favors LABA + LAMA Favors LABA + ICS

Wedzicha JA, Banerji D, Chapman KR, et al. Indacaterol-Glycopyrronium versus Salmeterol-Fluticasone for COPD. N Engl J Med. 2016;

FLAME Discussion

• LAMA + LABA is not inferior to LABA + ICS in reducing rate of

exacerbations

• Demonstrated that LAMA + LABA combination also lengthened time

between exacerbations compared to the standard of therapy

• Study was not powered to assess impact of the two treatment groups
• n severe exacerbations
• Some of the LABA + LAMA group recieved ICS prior to enrollment

Available LABA + LAMA agents

Brand Generic Dose FDA approval BevespiTM Aerosphere MDI Glycopyrrolate + formoterol 2 puffs BID 2016 UtibronTM Neohaler Glycopyrrolate + indacaterol 1 capsule BID 2015 StioltioTM Respimat MDI Tiotropium + olodaterol 2 puffs QD 2015 AnoroTM Ellipta DPI Umeclidinium + vilanterol 1 puff QD 2013 DuaklirTM Genuair DPI Aclidinium + formoterol 1 puff BID Seeking 2018

Question 7:

A 62 yo woman with GOLD stage 2 and is being discharged today for her 3rd COPD exacerbation this year. The doctor was planning to continue her home SymbicortTM and SpirivaTM. PMH: CAD, T2DM, osteoporosis and reports variable adherence to inhalers What medication change (if any) would you recommend to optimize therapy? A. Change to Umeclidinium + vilanterol (Anoro ElliptaTM) B. Discontinue SpirivaTM C. No changes, she is on optimum therapy D. Add Roflumilast

WISDOM Study - 2014

• Assess the impact of ICS withdrawal from triple therapy on COPD

exacerbations

• 52 week double blind, parallel group non-inferiority study (hazard ratio margin

1.2)

Tiotropium 18 mcg QD + Salmeterol 50 mcg BID + Fluticasone 500 mcg BID Triple Therapy x 6 weeks Continue triple therapy

VS

Withdraw Fluticasone 500 mcg BID in 3 steps over 12 weeks

Magnussen H, Disse B, Rodriguez-roisin R, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med. 2014;371(14):1285-94.

WISDOM Study Population

• n = 2485
• 64 year old males (82.5%)
• Mainly caucasian
• Average COPD diagnosis for 7.87 years with FEV1 < 50% (99.3%)
• Average FEV1 (34.2% predicted)

Magnussen H, Disse B, Rodriguez-roisin R, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med. 2014;371(14):1285-94.

WISDOM Results

Magnussen H, Disse B, Rodriguez-roisin R, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med. 2014;371(14):1285-94.

WISDOM Results

Magnussen H, Disse B, Rodriguez-roisin R, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med. 2014;371(14):1285-94.

WISDOM Results

• Primary endpoint

○ Withdrawing ICS from triple therapy was not inferior to continuing therapy when evaluating time to first moderate to severe exacerbation ○ Hazard ratio 1.06 (CI: 0.94 - 1.19)

• Secondary endpoints

○ Time to first severe exacerbation hazard ratio 1.2 ○ At 18 weeks the trough FEV1 was greater (38 mL) than those on triple therapy ○ No significant differences were noted for dyspnea or minor health status

• Safety

○ Incidence of pneumonia was similar between the groups

Magnussen H, Disse B, Rodriguez-roisin R, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med. 2014;371(14):1285-94.

WISDOM Discussion

• Shows ICS may not be needed in all COPD patients and can be safely

withdrawn without resulting in an increase in exacerbations

• Only specific populations likely continue to confer benefit from ICS

○

ie: Asthma - COPD Overlap Syndrome (ACOS)

• Generalizability was limited since population was mostly male and

Caucasian

• High dose ICS used (500 mcg BID)

Magnussen H, Disse B, Rodriguez-roisin R, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. N Engl J Med. 2014;371(14):1285-94.

RE2SPOND Study - 2016

The REACT study showed roflumilast is an effective add-on agent to decrease moderate or severe exacerbations and hospitalizations. RE2SPOND builds on REACT to determine which sub- group benefits most from roflumilast

• 52 week, multicenter, phase 4, RCT, double blind, placebo controlled

Any ICS + LABA + LAMA for > 3 months Roflumilast 500 mcg once daily x 52 weeks

VS

Placebo x 52 weeks

Martinez FJ, Rabe KF, Sethi S, et al. Effect of Roflumilast and Inhaled Corticosteroid/Long-Acting β2-Agonist on Chronic Obstructive Pulmonary Disease Exacerbations (RE(2)SPOND). A Randomized Clinical Trial. Am J Respir Crit Care Med. 2016;194(5):559-67.

RE2SPOND Population

• n = 2352
• 53% used ICS + LABA and remaining also had LAMA
• 64 year old males (85%)
• Mostly caucasian (80%)
• ~ 2.4 exacerbations/hospitalizations in the past year
• FEV1 = 33% predicted
• ~ 52.5 pack year smoking history

Martinez FJ, Rabe KF, Sethi S, et al. Effect of Roflumilast and Inhaled Corticosteroid/Long-Acting β2-Agonist on Chronic Obstructive Pulmonary Disease Exacerbations (RE(2)SPOND). A Randomized Clinical Trial. Am J Respir Crit Care Med. 2016;194(5):559-67.

RE2SPOND Design and Results

Outcomes Roflumilast Placebo RR (p-value) Primary Annual mod/severe exacerbation rate 1.17 1.27 0.92 p = 0.163 Did not achieve primary endpoint but shows trend that favors roflumilast Secondary Mean time to first exacerbation 319 days 286 days 0.9 p =0.323 Subgroup analysis Annual mod/severe exacerbation rate for those with hx >3 exacerbations/yr 1.59 2.62 0.61 p = 0.03 Annual mod/severe exacerbation rate for those with > 1 severe exacerbations/yr 1.23 1.63 0.77 p = 0.01

Martinez FJ, Rabe KF, Sethi S, et al. Effect of Roflumilast and Inhaled Corticosteroid/Long-Acting β2-Agonist on Chronic Obstructive Pulmonary Disease Exacerbations (RE(2)SPOND). A Randomized Clinical Trial. Am J Respir Crit Care Med. 2016;194(5):559-67.

• Those with > 3 exacerbations a year and those with > 1 severe

exacerbation in a year are the two populations that are most likely to benefit from roflumilast

• Limited ICS doses used in the study
• Maximum dose: fluticasone 250 mcg/salmeterol 50 mcg 1 BID
• Baseline population potentially were not on optimal therapy
• 47% were on concurrent LAMA (expected 60%)

RE2SPOND Discussion

Tie-COPD Study - 2017

Study to evaluating use of long term LAMA in mild to moderate COPD patients who have minimal symptoms

• 2 year, multicenter, RCT, double blinded, phase 4 trial

Tiotropium 18 mcg

VS

Placebo (LAMA) once daily

Zhou Y, Zhong NS, Li X, et al. Tiotropium in Early-Stage Chronic Obstructive Pulmonary Disease. N Engl J Med. 2017;377(10):923-935.

Tie-COPD Population

• n = 841
• Study subjects recruited from mainland China
• 64 year old males (85%)
• GOLD stage 1 - 2
• ~ 52.5 pack year smoking history
• FEV1 = 78% predicted
• Mean CAT score 7.1

Zhou Y, Zhong NS, Li X, et al. Tiotropium in Early-Stage Chronic Obstructive Pulmonary Disease. N Engl J Med. 2017;377(10):923-935.

Tie-COPD Design & Results

Outcomes LAMA Placebo P value Primary Mean change in FEV1 from baseline before SABD 38 mL 53 mL 0.06 Secondary Mean change in FEV1 from baseline after SABD 29 mL 51 mL 0.006 Number of any exacerbation

• r hospitalization per pt/yr

0.27 0.5 <0.001 Number of moderate/severe exacerbation per pt/yr 0.2 0.38 <0.001

Zhou Y, Zhong NS, Li X, et al. Tiotropium in Early-Stage Chronic Obstructive Pulmonary Disease. N Engl J Med. 2017;377(10):923-935.

Tie-COPD Discussion

• Roughly 70% of those with COPD have mild or minimal symptoms and

the majority do not receive maintenance treatment

• Provides evidence supporting benefit of early initiation of LABA
• Initiation of LAMA showed slower decline in FEV1 for those very early

in the disease progression (GOLD 1 and 2)

• Generalizability of the study is limited given that the majority of the

study population were Chinese

Zhou Y, Zhong NS, Li X, et al. Tiotropium in Early-Stage Chronic Obstructive Pulmonary Disease. N Engl J Med. 2017;377(10):923-935. Mapel DW, Dalal AA, Blanchette CM, Petersen H, Ferguson

• GT. Severity of COPD at initial spirometry-confirmed diagnosis: data from medical charts and administrative claims. Int J Chron Obstruct Pulmon Dis. 2011;6:573-81.

Post-Test

1. Which inhaled medication is no longer a preferred agent in the management of COPD? 2. Which inhaled medication(s) is now emphasized/ preferred in all ABCD severity groups? 3. What class of medications was added to step-up therapy for an exacerbation in a group D patient? 4. What are goals of treatment for improving inhaler technique? 5. Based on results from the FLAME study, which combination of inhaled medications lengthened time between exacerbations? 6. What did the results of the WISDOM study show in relation to withdrawing ICS from patients on triple therapy? 7. What population(s) was shown to benefit most from adding roflumilast to maintenance therapy? 8. What should be assessed in regard to medication use in all patients prior to escalating therapy in COPD?

Clinical Pearls

• Select appropriate inhaler device based on patient inspiratory flow rate
• Deterioration of inhaler technique over time, review administration

technique with patients

• Dual bronchodilator (LABA + LAMA) is a the new strategy for

managing COPD

• ICS therapy reserved for those at highest risk for exacerbations
• Roflumilast added to ICS + LABA ( +/- LAMA) therapy can reduce the

rate of moderate or severe exacerbations

Questions ?

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