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…

Pu

lmo

na

ry r

eha

b 2

5 O

ct –

6 N

ov

20

09

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