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COPD: Prevention

COPD: Prevention. Elizabeth Fomby, MD, MBA Associate Director, Scott & White Family Medicine Residency, Temple, TX Gemma Kim, MD, MS Associate Director, Scott & White Family Medicine Residency, Temple, TX John L. Manning, MD Program Director, Scott & White Family Medicine Residency, Temple, TX

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COPD: Prevention

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  1. COPD:Prevention Elizabeth Fomby, MD, MBAAssociate Director, Scott & White Family Medicine Residency, Temple, TX Gemma Kim, MD, MS Associate Director, Scott & White Family Medicine Residency, Temple, TX John L. Manning, MDProgram Director, Scott & White Family Medicine Residency, Temple, TX Janice K. Smith, MD, MPH Associate Director, Scott & White Family Medicine Residency, Temple, TX

  2. Educational Objectives At the end of this presentation, the learner should be able to … • Describe the importance of chronic obstructive pulmonary disease (COPD) prevention given its tremendous medical and economic burden • Discuss methods for primary prevention of COPD: • Smoking prevention • Avoidance of environmental causes • Smoking cessation • Discuss nonpharmacologic methods for secondary prevention of COPD (primarily prevention of exacerbation): • Avoidance of environmental factors • Limiting risks associated with exacerbations • Immunization strategies • Pulmonary rehabilitation

  3. Background • Significance of tobacco use is profound • Primary cause of COPD • Greatest cause of preventable death in U.S. • Estimated to have caused 5.4 million deaths in 2004 and 100 million deaths during 20th century • Epidemiology • 1.22 billion people were smoking in 2000; predicted to rise to 1.45 billion in 2010 and 1.5-1.9 billion by 2025 • Smoking 5 times more prevalent among males than females • Gender gap declines with younger age • Shift in prevalence of tobacco smoking to a younger demographic Lopez, 2006

  4. Background • Health effects of tobacco use • Risk of contracting COPD directly proportional to smoke exposure time and tar content or amount smoked • If someone stops smoking, at one year the risk of contracting heart disease is half that of continuing smoker • After 15 years of abstinence, risk similar to that for people who have never smoked.   • Smoking “light” cigarettes does not reduce one’s risks. • Tobacco use forms • Cigarettes, chewing tobacco, cigars, hookahs, snuff • Surgeon General’s Report: The Health Consequences of Smoking, 2004

  5. Background Mortality • Male and female smokers lose an average of 13.2 and 14.5 years of life, respectively • Smokers are 3 times as likely to die before age 60 or 70 as nonsmokers • In the U.S. cigarette smoking and exposure results in at least 443,000 premature deaths annually CDC, 2002; Mamun, 2004

  6. Background Youth tobacco use • In U.S., each day ~3,900 youths between 12 and 17 years of age smoke their first cigarette • Estimated 1,000 youth become daily cigarette smokers • 20% of high school students were current smokers in 2007 (18.7% females and 21.3% males) • TAR WARS • Tobacco free education program by American Academy of Family Physicians (AAFP) for children since 1988 • Provides students with tools to make positive health decisions and promote personal responsibility for their own well-being. • Has reached more than 8 million children with its tobacco-free message. CDC, 2002; Mamun, 2004

  7. Background Major health consequences of tobacco use • COPD • Cardiovascular disease Myocardial infarction Cerebral vascular accident Peripheral vascular disease • Cancer Lung Bladder Kidney Esophagus Larynx Pancreas Head and neck Stomach Breast Doherty, 1998; Almeida, 2002; Anstey, 2007; Jacobsen, 2004; Ness 1999

  8. Background Other health consequences of tobacco use • Influenza risk • Lung infection • Erectile dysfunction/decreased fertility • Osteoporosis • Behavioral • Cognitive function • Pregnancy • Miscarriage • Premature birth • Low birth weight Doherty, 1998; Almeida, 2002; Anstey, 2007; Jacobsen, 2004; Ness, 1999

  9. Prevention of Cigarette Smoking Public health and legislative measures • Mass media education campaigns • Smoke-free policies in workplace shown to double quit rates • Legislation to restrict smoking in public places, including schools - Smoke free legislation • Restricting minor’s access to tobacco products • Higher costs for tobacco products through increased excise taxes • Legislation to reduce tobacco advertising, promotions, and commercial availability of tobacco products Bauer, 2005; Bala, 2008

  10. Prevention of Cigarette Smoking Global Tobacco Surveillance System (GTSS) • Purpose is to enhance countries’ capacity to monitor tobacco use, guide national tobacco prevention and control programs, and facilitate comparison of tobacco-related data at national, regional, and global levels

  11. Prevention of Cigarette Smoking Youth tobacco prevention • Advertising for tobacco products and smoking in movies, TV shows, etc. has been shown to increase new tobacco use in adolescents • Media campaigns against smoking (e.g., TV and radio commercials, posters, magazine ads, etc.) • School-based tobacco-use prevention policies and programs (e.g., Tar Wars) • Sowden, 2000; Lovato, 2003; Thomas, 2006

  12. Prevention of Cigarette Smoking AAFP’s Tar Wars Program • Developed and sponsored by AAFP since 1988 • Reaches more than 400,000 youth per year in U.S. and abroad • Taught by volunteer physicians, teachers, medical students, residents, school nurses, and community members • Targets 4th and 5th graders with focus on: • Short-term, image-based consequences • Costs associated with tobacco use • Advertising techniques used by tobacco industry to influence youth • Short-term effectiveness measured in several studies Cain, 2006; Mahoney, 2002; Mahoney, 1998

  13. Prevention of Cigarette Smoking U.S. Preventive Services Task Force (USPSTF) • Recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products • Grade A recommendation USPSTF, 2010

  14. Prevention of COPD Avoidance of environmental factors • Environmental tobacco smoke (ETS) / passive exposure to cigarette smoke • Smoking bans and restrictions • Community education to reduce ETS in home • Occupational dusts and chemicals • Organic and inorganic dusts and chemical agents and fumes—use of masks/respirators in high-exposure occupations • Indoor air pollution • Burning of other biomass fuels such as wood, animal dung, crop residues, and coal in open fires or poorly functioning stoves • Outdoor air pollution • Ozone, particulate matter Jindal, 2006

  15. Smoking Cessation Treating Tobacco Use and Dependence: 2008 Update (U.S. Dept. of Health and Human Services) • Completed in 2008 to assist physicians in identifying counseling and medication treatments to aid/help patients quit smoking • Created by 24-member panel that reviewed more than 8,700 research articles between 1975 and 2007 • Fiore, 2008; U.S. Dept. of Health and Human Services, 2008

  16. Smoking Cessation Treating Tobacco Use and Dependence: 2008 Update Basic Findings • Tobacco dependence is a chronic condition • Seven first-line, FDA-approved medications were identified that increase success of quitting • Using counseling and medication treatment together increased success rates (Strength of Evidence [SOR]: A) • Quitlines (telephone or self-help web sites) are effective (SOR: B) • Individual, group, and telephone counseling works Fiore, 2008; U.S. Dept. of Health and Human Services

  17. Smoking Cessation Healthcare Effectiveness Data and Information Set (HEDIS)*: 2010 • Measures current smokers who were seen by practitioner during measurement year • Received advice to quit • Cessation medications recommended and discussed • Cessation methods recommended or discussed *—HEDIS is a tool used by more than 90% of America's health plans to measure performance on important dimensions of care and service. Widely used to measure physician’s performance.

  18. Smoking Cessation Combining Two Strategies Works Best • Nonpharmacologic Methods • Counseling • Individual • Groups • Telephone • Pharmacologic Methods • Seven first-line drugs • Nicotine replacement therapy (NRT) • Psychotropic agents • Partial nicotine receptor agonist • Second-line drugs (not yet FDA approved for cessation) • Combination drug therapy (NRT & other medication) Fiore, 2008; U.S. Dept. of Health and Human Services

  19. Smoking Cessation Nicotine withdrawal symptoms • Anxiety • Depression • Insomnia • Irritability • Frustration and anger • Increased appetite • Increased cravings • Decreased concentration

  20. Smoking Cessation Nonpharmacologic Methods Counseling essentials: • “5 A’s” behavioral counseling construct developed by the National Cancer Institute (SOR: A) • Ask: Do you smoke? Use any tobacco products? Ask at every visit • Advise: You should quit • Assess: Willingness to quit or history of attempts to quit • Assist: If willing, design a quit plan. If not ready, motivate. If already quit, relapse prevention. • Arrange: Follow up. Are you still not smoking? • Brief counseling (SOR: A) • Ask: Do you smoke? • Advise: You should quit • Refer: Other resources, such as tobacco quit line

  21. Question Which of these counseling techniques do you think provides the greatest likelihood of achieving successful tobacco cessation? • Group counseling • Individual counseling • Brief physician advice • Motivational interviewing

  22. Smoking Cessation Nonpharmacologic methods Counseling essentials: • Brief physician advice: Link to Ask & Act • Increases quit rates • Individual counseling • Variable success • In adolescent population, counseling approximately doubles long-term abstinence rates (SOR: B) • Group counseling • More effective than self-help materials and brief advice • Motivational interviewing • More successful than brief advice Stead, 2005, 2008; Lai, 2010; Sorio, 2006; Rolnick, 2010

  23. Smoking Cessation Nonpharmacologic methods Counseling essentials: • Telephone support (SOR: A) • 3 or more telephone calls increases chances of quitting • Quitlines • Provide important route of access and support • 1-800-QUIT-NOW (1-800-784-8669) • Self-help interventions • May increase quit rates, but minimal impact • E-health tobacco interventions • Showing positive results Fiore, 2008; Stead, 2006; Lancaster, 2005

  24. Smoking Cessation Pharmacologic Therapy • Long-term use • Can be beneficial to patients who have persistent withdrawal symptoms • Long-term use of nicotine replacement therapy (NRT) appears to not have any long-term health risks • FDA recommends • Bupropion for up to 6 months • Varenicline for 12 weeks, may repeat for an additional 12 weeks • Combination therapy • Increased long-term abstinence with combination of nicotine patch + other NRT (i.e.,gum or spray) (SOR: A) • Nicotine patch with bupropion more effective than patch alone (SOR: A) Fiore, 2008

  25. Smoking Cessation Stead, 2008

  26. Smoking Cessation NRT • Mechanism of action • Binds to central nervous system (CNS) and peripheral nicotine cholinergic receptors • Works by reducing physical craving for nicotine • Allows patient to focus on behavioral and psychological aspects of tobacco cessation • Precautions • Recent myocardial infarction (MI) within past 2 weeks • Serious arrhythmia • Unstable angina Fiore, 2008; Stead, 2008

  27. Smoking Cessation NRT • Side effects • Mouth soreness • Dyspepsia • Hiccups • Not recommended • Smokeless tobacco users • Smokers using fewer than 10 cigarettes per day • Adolescents • Pregnancy

  28. Smoking Cessation Nicotine gum (SOR: A) • Amount • > 25 cigarettes per day: 4 mg, 1 piece every 1-2 hours for first 6 weeks • < 25 cigarettes per day: 2 mg, 1 piece every 1-2 hours for first 6 weeks, then begin tapering • Directions for chewing • Chew slowly • Stop chewing after noticing peppery taste or tingling sensation • Store in between cheek and gum • Cost: $$$

  29. Smoking Cessation Nicotine lozenges (SOR: B) • Amount • Based on time of first cigarette of day • If cigarette within 30 minutes of waking, use 4-mg lozenge • Dosing forms 2 mg and 4 mg • Directions • Use every 1-2 hours for first 6 weeks, then tapering to every 2-4 hours • Cost: $$$

  30. Smoking Cessation Nicotine nasal spray (SOR: A) • Amount • Start with 2 sprays, one squirt in each nostril • Directions • One squirt in each nostril, using 1-2 doses every hour, (maximum dosing - 5 doses per hour) • Side effects • Hot peppery taste • Sneezing • Cough • Watery eyes • Runny nose • Cost: $$$

  31. Smoking Cessation Nicotine inhaler (SOR: A) • Amount • Delivers 4 mg of nicotine • Directions • Start with 6 cartridges daily for first 3-6 weeks • Maximum: 16 cartridges daily • Recommended for up to 3 months • Side effects • Cough • Headache • Rhinitis • Dyspepsia • Mouth irritation • Cost: $$$

  32. Smoking Cessation Nicotine patch (SOR: A) • Amount • Dosing forms: 7, 14, and 21 mg • < 10 cigarettes per day: start with 14-mg patch for 6 weeks, decreasing to 7 mg for additional 2 weeks • > 10 cigarettes per day: start with 21-mg patch for 6 weeks, reducing to 14 mg for 2 weeks, and 7 mg for 2 weeks • Directions • Apply to upper body/upper outer part of arm • Side effects • Localized itching burning and tingling • Cost: $$

  33. Smoking Cessation Bupropion SR (SOR: A) • Mechanism of action • Antidepressant • Inhibit uptake of norepinephrine, serotonin, and dopamine • Decreases craving of cigarettes and reduces symptoms of nicotine withdrawal • Dosing and directions • 150 mg every morning for 3 days, then increase to 150 mg twice daily • Start therapy before quitting, 1-2 weeks • Can be safely used with NRT • Duration: 7-12 weeks

  34. Smoking Cessation Bupropion SR • Side effects • Dry mouth • Insomnia • Lowered seizure threshold • Nervousness and difficulty concentrating • Precautions and adverse effects • Seizures • Careful if patient has hepatic cirrhosis • Pregnancy (Category C) • Avoid using in patients undergoing abrupt discontinuation of alcohol or sedatives • Cost: $$$

  35. Smoking Cessation Varenicline (SOR: A) • Mechanism of action • Nicotine acetylcholine receptor partial agonist: newest type of therapy for smokers • Competitively inhibits binding of nicotine • Dosing and directions • Days 1-3: 0.5 mg daily • Days 4-7: 0.5 mg twice daily • Weeks 2-12: 1 mg twice daily • Patient should begin therapy 1 week before quit date • Duration of treatment: 12 weeks, up to 24 weeks • Not to be used with NRT Jorenby, 2006

  36. Smoking Cessation Varenicline • Side effects • Nausea • Insomnia • Nightmares • Abnormally vivid dreams • Precautions and adverse effects • Neuropsychiatric symptoms (e.g., behavior changes, agitation, depressed mood, suicidal ideation) • Caution with severe renal impairment • Pregnancy (Category C) • Cost: $4.90-$5.18 daily

  37. Smoking Cessation Second-line pharmacologic therapy Clonidine • May be used under a physician's supervision (SOR: A); not FDA approved for this use • Approximately doubles abstinence rates • Dose varies from 0.1 to 0.75 mg per day and delivered transdermally or orally • Cost: Oral $, transdermal $$$ Fiore, 2008

  38. Smoking Cessation Second-line pharmacologic therapy Nortriptyline • Almost doubles a smoker's likelihood of achieving long-term cessation • 75 to 100 mg per day for 6 to 13 weeks of treatment • Cost: $ Fiore, 2008

  39. Question Which of the following combination therapies are contraindicated for use as a tobacco cessation aid? • Nicotine patch plus bupropion • Nicotine patch plus paroxetine • Nicotine patch plus nicotine gum • Nicotine patch plus varenicline

  40. Smoking Cessation Combination therapy effective (SOR: A) Adapted from Fiore, 2008

  41. Smoking Cessation System approaches Tobacco use treatments cost-effective • Evidence-based tobacco dependence interventions produce favorable return on investment for employers and health plans • Insurance coverage of tobacco cessation counseling and pharmacologic treatment increases quit rates • Tobacco cessation counseling is reimbursable and has specific ICD-9 and E/M codes. • Medicare covers cost of up to 8 counseling sessions per year for tobacco cessation Fiore, 2008

  42. Smoking Cessation Recommendations for clinical practice (SOR:A) • All patients should be asked if they use tobacco • Clinic screening systems significantly increase rates of clinician intervention • Expand the vital signs to include tobacco use status • Use of other reminder systems such as chart stickers or computer prompts • Every tobacco user should be offered at least a minimal intervention including brief physician advice • Most smokers have multiple quit attempts (7-20) before being successful. Follow-up support and praise for efforts important Fiore, 2008

  43. Smoking Cessation Recommendations for clinical practice (SOR: A) • Strong dose-response relation between session length of person-to-person contact and successful treatment outcomes • Counseling plus medication is better than either method alone • Some combination drug therapies may be more effective than single drug therapy • All physicians should strongly advise every patient who smokes to quit Fiore, 2008

  44. Smoking Cessation Alternative therapies Insufficient evidence regarding effectiveness of these and other non-traditional modalities for cessation of tobacco use or prevention of COPD exacerbations: • Herbal medicines (e.g., St. John’s wort, ginsing, lobelia) • Acupuncture • Massage therapy • Homeopathic medicine • Nicobrevin or silver acetate • Hypnotherapy Fiore, 2008; Berge, 2009

  45. Secondary Prevention Secondary prevention focuses on prevention of acute exacerbations An acute exacerbation is defined as … “an event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and /or sputum that is beyond normal day-to-day variations, is acute in onset and may warrant a change in regular medication” Rabe 2007

  46. Secondary Prevention Exacerbations are thought to be related to an interaction of host factors, bacteria, viruses, and changes in air quality, leading to increased inflammation of the lower respiratory tract. Early recognition and treatment of acute exacerbations can significantly reduce: • Morbidity • Poor health-related quality of life • Health care expenditures • Mortality related to this disease White, 2003; Rohde, 2003

  47. Secondary Prevention Risk factors for exacerbation • Age: older than 65 years • FEV1 ≤ 50% of predicted • ≥ 3 exacerbations in past 12 months • Poor physical activity • Poor social support • Comorbidities • Coronary disease • Heart failure • Diabetes • Renal failure • Hepatic failure • Low body weight: body mass index (BMI) ≤ 20 kg/m2 Garcia-Aymerich, 2001

  48. Secondary Prevention Methods for secondary prevention • Avoidance of environmental factors • Lowering risks for exacerbation • Immunization strategies • Pulmonary rehabilitation • Long-term oxygen therapy and other pharmacologic interventions American Thoracic Society, 2004

  49. Secondary Prevention: Environmental Factors • Ozone, sulphur dioxide, nitrogen dioxide, and particulate matter including diesel particulates • Increase airway inflammation • Stimulate production of pro-inflammatory cytokines, neutrophil production, and methylhistamine • Potentially lead to exacerbations • Epidemiologic studies have shown … • Increased hospitalization rates when atmospheric pollution high • Increased risk of death in COPD patients with increased urban particle air pollution White, 2003; Laumbach, 2010

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