O slideshow foi denunciado.
Utilizamos seu perfil e dados de atividades no LinkedIn para personalizar e exibir anúncios mais relevantes. Altere suas preferências de anúncios quando desejar.

Updates on pharmacological management of COPD 2020

3.634 visualizações

Publicada em

..

Publicada em: Saúde e medicina
  • Entre para ver os comentários

Updates on pharmacological management of COPD 2020

  1. 1. 1
  2. 2. By
  3. 3. WORLD LUNG DAY 2019:Cape Town, Glenview, Lausanne, Montevideo, New York, Paris, Tokyo, 25 September 2019
  4. 4. SYMPTOMS Cough Sputum Shortness of breath EXPOSURE TO RISK FACTORS Tobacco Occupation Indoor/outdoor pollution SPIROMETRY Diagnosis of COPD èèè
  5. 5. Assessment of Symptoms  Best way to assess symptoms is to use validated questionnaires:  Modified Medical Research Council dyspnea scale.  MMRC  COPD Assessment Test  CAT
  6. 6. Assessment of Exacerbation Risk  COPD exacerbations are defined as an acute worsening of respiratory symptoms that result in additional therapy.  Classified as: o Mild (treated with SABDs only) o Moderate (treated with SABDs plus antibiotics and/or oral corticosteroids) o Severe (patient requires hospitalization or visits the emergency room). Severe exacerbations may also be associated with acute respiratory failure.  Blood eosinophil count may also predict exacerbation rates (in patients treated with LABA without ICS). © 2019 Global Initiative for Chronic Obstructive Lung Disease
  7. 7. The Refined ABCD assessment tool: overview
  8. 8. The Refined ABCD assessment tool: overview C D A B FEV1 (% predicted) GOLD 1 ≥ 80% GOLD 2 50-79 GOLD 3 30-49 GOLD 4 < 30 Post- bronchodilator FEV1/FVC < 0.7 ≥ 2 or ≥ 1 leading to hospital admission 0 or 1 (not leading to hospital admission) Spirometrically confirmed diagnosis Assessment of airflow limitation Assessment of symptoms/risk of exacerbations Exacerbation history Symptoms CAT < 10 CAT > 10 mMRC 0–1 mMRC > 2
  9. 9. FOR INTERNAL USE ONLY. STRICTLY CONFIDENTIAL. DO NOT COPY, DETAIL OR DISTRIBUTE EXTERNALLY. COPD Assessment Tool : GOLD 2017
  10. 10. FOR INTERNAL USE ONLY. STRICTLY CONFIDENTIAL. DO NOT COPY, DETAIL OR DISTRIBUTE EXTERNALLY.
  11. 11. Children’s Healthcare of Atlanta 39
  12. 12.  A diagnosis of COPD is based on the presence of symptoms and obstruction demonstrated by a post-bronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio of less than 0.7 on spirometry.  The degree of FEV1 impairment, expressed as a percentage of the predicted value, is used to determine the GOLD stage (1 to 4).
  13. 13.  The severity of symptoms as determined by the Modified Medical Research Council breathlessness score [mMRC] or the COPD Assessment Test [CATTM]) and  The risk of exacerbations (based on the number of moderate or severe exacerbations in the previous year) are used to determine patient’s GOLD group (A to D).
  14. 14. COPD Goals of Therapy 48 Reduce Symptoms  Relieve symptoms  Improve exercise tolerance  Improve health status Reduce Risk  Prevent disease progression  Prevent and treat exacerbations  Reduce mortality GOLD 2017
  15. 15. Road Map
  16. 16. GOLD assessment tool balances grade number and letter to designate COPD severity
  17. 17. 2018 Global Strategy for Diagnosis, Management and Prevention of COPD.
  18. 18. 2018 Global Strategy for Diagnosis, Management and Prevention of COPD.
  19. 19. 2018 Global Strategy for Diagnosis, Management and Prevention of COPD.
  20. 20. 2018 Global Strategy for Diagnosis, Management and Prevention of COPD.
  21. 21. Treatment algorithms GOLD 2019  The latest iteration of the GOLD treatment algorithms has changed dramatically from 2017.  GOLD still uses the Refined Assessment Tool that was introduced in 2017 to categorise COPD into four groups (A, B, C and D) based on symptoms and risk of exacerbations .  Although it continues to use FEV1 to grade severity, this is not part of the assessment tool.
  22. 22. © 2019 Global Initiative for Chronic Obstructive Lung Disease
  23. 23. The 2019 report emphasises that this assessment of symptom severity & exacerbation risk is recommended only as a basis for determining initial therapy and is not designed for reassessing patients during follow up.
  24. 24.  The 2019 report clearly separating recommendations for initial therapy (which have now been simplified), from recommendations about how to escalate or de-escalate therapy based on changes in the patient’s breathlessness or exacerbation frequency.
  25. 25. © 2019 Global Initiative for Chronic Obstructive Lung Disease
  26. 26. © 2019 Global Initiative for Chronic Obstructive Lung Disease
  27. 27. Initial Pharmacological Treatment of stable COPD
  28. 28. Initial pharmacotherapy  The updated guidelines continue to recommend the utilization of the ABCD assessment tool for the initial treatment of COPD, but no longer recommend its use to adjust treatment thereafter.  There are two separate algorithms, one for initiation of therapy and another for follow-up treatment
  29. 29. Initial pharmacotherapy  The 2019 report continues to recommend that patients are diagnosed and assessed as described in the 2017 version.  The Initial treatment is based upon which of the four groups the patient falls into at diagnosis  The treatment options in each group have been greatly simplified since 2017.
  30. 30.  According to the GOLD 2019 Global Strategy for the Diagnosis, Management, and Prevention of COPD guideline update, first-line pharmacologic therapy depends on the patient’s GOLD group classification (A, B, C, D).  The GOLD 2019 guidelines do not include the preferred treatment algorithm.  Short-acting bronchodilators (short-acting muscarinic antagonist [SAMA] or short-acting inhaled beta2 agonist [SABA]) should be prescribed to all patients for immediate symptom relief, regardless of their GOLD classification.
  31. 31. © 2019 Global Initiative for Chronic Obstructive Lung Disease
  32. 32.  For Group A patients, a short- or long-acting bronchodilator (long-acting muscarinic antagonist [LAMA] or long-acting beta2 agonist [LABA]) is recommended based on their effects on patients’ breathlessness. (depending on the intensity and frequency of symptoms). Group A
  33. 33. © 2019 Global Initiative for Chronic Obstructive Lung Disease
  34. 34.  Initial therapy should consist of a long acting bronchodilator (LABA or LAMA).  For Group B patients, the guidelines do not recommend one class of long-acting bronchodilator over another for initial symptoms.  Initial therapy with two long-acting bronchodilators may be considered in patients who are experiencing severe breathlessness on monotherapy. Group B
  35. 35. © 2019 Global Initiative for Chronic Obstructive Lung Disease
  36. 36.  For patients classified in Group C,initial therapy should consist of a single long-acting bronchodilator.  LAMAs are superior to LABAs regarding COPD exacerbation prevention , therefore we recommend starting therapy with a LAMA in this group. Group C
  37. 37. © 2019 Global Initiative for Chronic Obstructive Lung Disease
  38. 38.  In general, therapy can be started with a LAMA as it has effects on both breathlessness and exacerbations.  In Group D, a LAMA/LABA combination can be chosen as initial treatment in patients experiencing more severe symptoms, such as greater dyspnea and/or exercise intolerance (order of magnitude of CAT™ ≥ 20) . Group D
  39. 39.  The 2019 guideline update recommends a LABA/ICS combination for initial treatment in some patients with an eosinophil count greater than 300 cells/µL or those with a history of asthma and COPD.  ICS may cause side effects such as pneumonia, so should be used as initial therapy only after the possible clinical benefits versus risks have been considered. Group D
  40. 40.  Bronchodilators are still the recommended initial treatment for patients in groups A, B, and C.  The choice of initial therapy for patients in group D, who are both symptomatic and at risk of exacerbations, depends on the intensity of symptoms and may also be influenced by the blood eosinophil count.
  41. 41.  If patients is in group D , A LAMA is the recommended initial therapy unless the patient is highly symptomatic (e.g. CAT score >20), in which case dual bronchodilator therapy with a LAMA plus a long-acting beta agonist is recommended.  If patients in group D have a blood eosinophil count of ≥300 cells/μl, initial therapy with a LABA+ICS can also be considered.
  42. 42.  The use of ICS is no longer recommended in GOLD Group C for initial therapy.  ICS are only recommended for initial treatment in patients that fall into Group D with elevated EOS count ≥ 300 cells/µL.
  43. 43.  The 2019 update focuses on using the ABCD assessment to determine initial treatment only and then utilizing the management cycle to follow- up and make changes to treatment.  The management cycle involves a three step process: review, assess, and adjust, designed to treat COPD based on symptoms and exacerbations.  Recommendations at follow-up are no longer dependent on the patient’s GOLD group (A, B, C, D) at diagnosis.
  44. 44.  The guideline recommended three steps be conducted at each visit to ensure appropriate management of COPD.  At each visit, a provider should: 1. Review symptoms 2. Assess inhaler technique, adherence and non-pharmacological approaches (such as smoking cessation, pulmonary rehabilitation, exercise training, etc.) 3. Adjust medications if needed.
  45. 45.  If a patient’s current treatment achieves treatment goals, no changes in treatment are recommended during assessment.  If the treatment is not optimized, consider therapy changes based on separate dyspnea and exacerbation algorithms.  If a patient presents with both dyspnea and an exacerbation, the exacerbation algorithm should be used.
  46. 46.  Follow-up treatment is now based on whether the patient has continued breathlessness or frequent exacerbations but not on the patient’s GOLD group at diagnosis (even though we can see that GOLD grouping is actually based on symptoms and exacerbations).
  47. 47. FOLLOW-UP pharmacological treatment Dyspnea  For patients with persistent breathlessness or exercise limitation on long acting bronchodilator monotherapy, the use of two bronchodilators is recommended.  If the addition of a second long acting bronchodilator does not improve symptoms, we suggest the treatment could be stepped down again to monotherapy.  Switching inhaler device or molecules can also be considered.
  48. 48. FOLLOW-UP pharmacological treatment Dyspnea  For patients with persistent breathlessness or exercise limitation on LABA/ICS treatment, LAMA can be added to escalate to triple therapy.  Alternatively, switching from LABA/ICS to LABA/LAMA should be considered if the original indication for ICS was inappropriate (e.g., an ICS was used to treat symptoms in the absence of a history of exacerbations), or there has been a lack of response to ICS treatment, or if ICS side effects warrant discontinuation.
  49. 49. FOLLOW-UP pharmacological treatment Dyspnea  At all stages, dyspnea due to other causes (not COPD) should be investigated and treated appropriately.  Inhaler technique and adherence should be considered as causes of inadequate treatment response.
  50. 50. Dyspnea
  51. 51. FOLLOW-UP pharmacological treatment Exacerbations  For patients with persistent exacerbations on long acting bronchodilator monotherapy, escalation to either LABA/LAMA or LABA/ICS is recommended.  LABA/ICS may be preferred for patients with a history or findings suggestive of asthma.  Blood eosinophil counts may identify patients with a greater likelihood of a beneficial response to ICS.
  52. 52. FOLLOW-UP pharmacological treatment Exacerbations  For patients with one exacerbation per year, a peripheral blood level ≥ 300 eosinophils/µL identifies patients more likely to respond to LABA/ICS treatment.  For patients with ≥ 2 moderate exacerbations per year or at least one severe exacerbation requiring hospitalization in the prior year, LABA/ICS treatment can be considered at blood eosinophil counts ≥ 100 cells/µL, as ICS effects are more pronounced in patients with greater exacerbation frequency and/or severity.
  53. 53. FOLLOW-UP pharmacological treatment Exacerbations  In patients who develop further exacerbations on LABA/LAMA therapy we suggest two alternative pathways.  Blood eosinophil counts < 100 cells/µL can be used to predict a low likelihood of a beneficial ICS response: 1) Escalation to LABA/LAMA/ICS. A beneficial response after the addition of ICS may be observed at blood eosinophil counts ≥ 100 cells /µL, with a greater magnitude of response more likely with higher eosinophil counts. 2) Add roflumilast or azithromycin if blood eosinophils < 100 cells/µL.
  54. 54. Exacerbations
  55. 55. For the first time, GOLD has introduced the use of blood eosinophil count as a circulating biomarker to help guide treatment choice.
  56. 56.  Eosinophilic airway inflammation is present in a subset of patients with COPD and blood eosinophil counts have been used as a practical biomarker of eosinophilic airway inflammation in patients with COPD.  Studies have shown that blood eosinophil counts are not reliable as predictors of the risk of exacerbations, but analysis of recent clinical trials has shown that eosinophil counts are consistently predictive of the efficacy of ICS in exacerbations.  Low eosinophil counts are predictive of a higher risk of developing pneumonia.
  57. 57. FOLLOW-UP pharmacological treatment Exacerbations ►If patients treated with LABA/LAMA/ICS who still have exacerbations the following options may be considered:  Add roflumilast. This may be considered in patients with an FEV1 < 50% predicted and chronic bronchitis, particularly if they have experienced at least one hospitalization for an exacerbation in the previous year.  Add a macrolide. The best available evidence exists for the use of azithromycin, especially in those who are not current smokers. Consideration to the development of resistant organisms should be factored into decision-making.
  58. 58. FOLLOW-UP pharmacological treatment Exacerbations  In patients who develop further exacerbations on LABA/ICS therapy, we recommend escalation to triple therapy by adding a LAMA.  Alternatively, treatment can be switched to LABA/LAMA if there has been a lack of response to ICS treatment, or if ICS side effects warrant discontinuation .
  59. 59. De-escalation of treatment  De-escalation strategies are currently limited to patients who are taking ICS.  De-escalation of ICS can be considered if: 1. The patient experiences pneumonia 2. There was an inappropriate indication for the ICS when they were first prescribed 3. There was a lack of response (i.e. no change in the frequency of exacerbations following the introduction of ICS therapy).  De-escalation may also be considered in patients with COPD receiving treatment who return with resolution of some symptoms that subsequently may require less therapy.
  60. 60. De-escalation of treatment  For patients who have had their treatment de-escalated, it is important to monitor them under close medical supervision to ensure they do not deteriorate as a result of the changes.  A blood eosinophil count ≥ 300 cells /µL identifies patients with the greatest likelihood of experiencing more exacerbations after ICS withdrawal and who subsequently should be followed closely for relapse of exacerbations.
  61. 61. 112
  62. 62. © 2019 Global Initiative for Chronic Obstructive Lung Disease
  63. 63. FOLLOW-UP pharmacological treatment
  64. 64. GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE (GOLD): TEACHING SLIDE SET 2020
  65. 65. © 2019 Global Initiative for Chronic Obstructive Lung Disease
  66. 66. © 2019 Global Initiative for Chronic Obstructive Lung Disease
  67. 67. 123 Thank you

×