Chronic Obstructive Lung Disease: GOLD Guidelines

1. Chronic Obstructive Lung Disease:GOLD Guidelines • Baylor College of Medicine • Combined Med-Peds Program • Anoop Agrawal, M.D.

2. COPD - Definition • Global Obstructive Lung DiseaseGuidelines (GOLD) : first published in 2001 • “Disease state characterized by airflow limitation that is no longer fully reversible and is usually progressive... This results in a chronic inflammatory response in the walls and lumen of the airways.” • GOLD guidelines were recently updated in 2006

3. COPD - Prevalence • Affects 15 million Americans • Fourth leading cause of mortality (100,000/year) • Only major health problem for which mortality has been increasing for past 20 years • Results in 500,000 hospitalizations/year • Second leading cause of missed work days • There are numerous published guidelines - GOLD being the most prominent (www.goldcopd.com)

4. COPD - Risk Factors • Hereditary - Alpha-1 Antitrypsin Deficiency • Environmental • Cigarette Smoking • What percent of smokers will develop COPD? • 15-20% (~1 in 5) - this implies a genetic predisposition to developing COPD; tends to cluster in families • Occupational exposures to dust, chemicals

5. COPD - Diagnosis • Symptoms • chronic cough - intermittent, nonproductive • cough with sputum production, ‘smoker’s cough’ • dyspnea on exertion, usually progressive and indolent • Spirometry • Should spirometry screening be performed on the general population? • No, but in those with higher risk - i.e. all current and former smokers over the age of 40 years with any of the above symptoms of disease

6. The Importance of Screening for COPD • The Rule of 50s • 50% of COPD patients are undiagnosed (or approximately 12 million patients in U.S.) • COPD is evident by age 50 • At time of diagnosis, FEV1 is <50% predicted • 50% 5-year survival rate

7. Raising COPD Awareness November is National COPD Awareness Month World COPD Day took place on November 19th, 2008.

8. COPD Staging • Based upon the GOLD Guidelines - 2006 update • Classified into 4 stages • Staging is based primarily upon FEV1: • FEV1 < 80% • FEV1:FVC < 70% • The lower the FEV1 the more severe the disease classification.

9. GOLD Guidelines for Therapy

10. COPD Management and Therapies • Vaccination - pneumococcal and influenza • Regular Assessment of lung function - annually • Cessation of tobacco use • Drug Therapy: • short acting vs. long acting bronchodilators • inhaled vs. oral corticosteroids

11. COPD - Management of Stable Disease • Smoking cessation: rate of FEV1 deterioration will slow to near normal (20 ml /yr vs. 65 ml /yr for active smokers) if patient stops smoking

12. COPD - Drug Therapy • Therapy recommendations based on their effect on FEV1. • First Line therapy: • Beta agonists - short and long acting • Anticholinergics - short and long acting • Second Line therapy: • Steroids - inhaled vs. oral • Supplemental therapies

13. Beta agonists • Mechanism of Action - bronchodilate by stimulating Beta-2 receptors • Studies show that COPD patients do not develop tolerance to short acting or long acting beta agonists • Asthmatics tend to develop tolerance to short acting agonists • Can Salmeterol be used as monotherapy? YES, salmeterol monotherapy had adverse outcomes in asthma study, note copd.

14. Anticholinergics • Mechanism of action- bronchodilation by decreasing airway smooth muscle tone • Also reduces sputum production • Combination of an anticholinergic + B2-agonist produces greater and more sustained rise in FEV1 than either drug alone.

15. Tiotropium (Spiriva) • Studies show that once daily tiotropium has resulted in a lasting increase in FEV1 out to one year. • 174 ml above baseline in good short-term responders • 56 ml increase in poor short-term responders Special delivery device. Tashkin,D. Chest 2003 May; 123:1441-9

16. Inhaled Corticosteroids (ICS) • Have not been shown to slow the progression of disease or provide long term benefit • ISOLDE trial - patients with FEV1 of 50% predicted value had a 25% reduction of exacerbations • Combination with salmeterol more effective in reducing exacerbations than either drug alone • Unfortunately, recently published trial failed to demonstrate statistically significant reduction in mortality with salmeterol/fluticasone combo. • Use of ICS increases likelihood of pneumonia.

17. New COPD Treatment Data • INSPIRE - study published in Jan 2008 • compared salmeterol/fluticasone head to head with tiotropium • No difference in exacerbation rate although more in tiotropium group had higher drop out rate. • More patients in salmeterol/fluticasone developed pneumonia.

18. Oral Corticosteroids • They have no proven benefit in stable COPD • Oral steroids are useful for acute exacerbations • What is the recommended duration of therapy? • Maximum benefit obtained during first 2 weeks of therapy.

19. Supplemental Therapies • Supplemental oxygen for hypoxemia (worn for more than 15 hrs/day) has been shown to reduce moratality • What are the qualification parameters for oxygen therapy? • PaO2 of 55mmHg or less, or pulse oximetry of 88% or less • Pulmonary Rehabilitation • Lung reduction and lung transplantation surgeries

20. GOLD Guidelines for Therapy

21. Summary • Early diagnosis, disease prevention, smoking cessation and vaccination are important. • Initiate bronchodilator therapy early in disease course, combination of albuterol with ipratropium most effective • Inhaled corticosteroids may be useful in patients with severe disease or with objective responses on spirometry. • Will likely see inflammatory modulators (TNF-α) in the future