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COPD: New classification , new drugs Medicine Review Course 9 Sep 2012
Dr Augustine Tee Dept. of Respiratory Medicine
GOLD 2011 revision
COPD, a common preventable & treatable disease, is characterized by persistent airflow limitation that is usually progressive & associated with an enhanced chronic inflammatory response in the airways & the lung to noxious particles or gases.
Exacerbations & comorbidities contribute to the overall severity in individual patients.
Definition
“Spirometry is required to make the diagnosis in this clinical context; …”
www.goldcopd.org
Assessment of COPD (Revised GOLD document 2011)
•MMRC grade or CAT score
Symptoms
•Spirometry Grades (NOT Stage)
Airflow Limitation
•History of exacerbation & spirometry grade
•2 or > exacerbations in last 1 year
•FEV1 < 50%
Risk of Exacerbation
•CVD
•Depression
•Osteoporosis
Co-morbidities
Assessing symptoms & their impact
Are you breathless?
Do you have cough?
Do you have phlegm?
Yes Yes
Yes
Have been like that for many years, I have learnt to cope with
it…
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Classification of severity of airflow limitation in COPD (based on post-bronchodilator FEV1)
Grades (in patients with FEV1/FVC <0.70)
GOLD 1 Mild FEV1 ≥ 80% predicted
GOLD 2 Moderate 50% ≤ FEV1 < 80% predicted
GOLD 3 Severe 30% ≤ FEV1 < 50% predicted
GOLD 4 Very Severe FEV1 < 30% predicted
Exacerbations of COPD
An exacerbation of COPD is an acute event characterized by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations & leads to a change in medication.
2011
Global Strategy for Diagnosis, Management and Prevention of COPD
Assess COPD Comorbidities
COPD patients are at increased risk for:
• Cardiovascular diseases
• Osteoporosis
• Respiratory infections
• Anxiety and Depression
• Diabetes
• Lung cancer
These comorbid conditions may influence mortality and hospitalizations and should be looked for
routinely, and treated appropriately.
IV: Very Severe III: Severe II: Moderate I: Mild
Therapy at Each Stage of COPD
FEV1/FVC < 70%
FEV1 > 80% predicted
FEV1/FVC < 70%
50% < FEV1 < 80% predicted
FEV1/FVC < 70%
30% < FEV1 < 50% predicted
FEV1/FVC < 70%
FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure
Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation
Add inhaled glucocorticosteroids if repeated exacerbations
Active reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator (when needed)
Add long term oxygen if chronic respiratory failure. Consider surgical treatments
GOLD guidelines 2010
GOLD revision (2011): Treatment strategy
C Severe Disease
Frequent exacerbations
Minimal Symptoms
D Severe Disease
Frequent exacerbations
Significant Symptoms
A Milder Disease
Few exacerbations
Minimal Symptoms
B Milder Disease
Few exacerbations
Significant Symptoms
CAT <10 MRC 0 - 1
CAT ≥10 MRC ≥2
Symptoms
4 3 2 1
Spirometric Grades
Ris
k
(A
irfl
ow
Lim
itati
on
)
Ris
k
(exacerb
atio
n h
isto
ry)
≥ 2
0 - 1
2011 Treatment strategy: 1st choice (2nd choice)
C ICS/LABA OR
LAMA
(LABA & LAMA)
D ICS/LABA AND
LAMA
(add PDE4 inhibitor)
A SABA OR SAMA
prn
(SABA & SAMA)
B LABA OR LAMA
(LABA & LAMA)
CAT <10 MRC 0 - 1
CAT ≥10 MRC ≥2
Symptoms
4 3 2 1
Spirometric Grades
Ris
k
(A
irfl
ow
Lim
itati
on
)
Ris
k
(exacerb
atio
n h
isto
ry)
≥ 2
0 - 1
Soft Mist Inhaler (Respimat®)
Ultra-long acting beta2-agonist (Indacaterol) Phase 3 trials: Olodaterol, Vilanterol
Phosphodiesterase-4 inhibitor (Roflumilast)
Calverley et al. Lancet 2009
FEV1 ≤ 50% predicted
Chronic cough & sputum
At least 1 exacerbation in previous year
Bronchoscopic Lung Volume Reduction: Endobronchial valve therapy
Thank You