Update on COPD & Asthma

Disclosures

• No Pharma Consulting, Research, Lectures • NHLBI - Asthma Clinical Research Network

• NHLBI - COPD Clinical Research Network • NAEPP Coordinating Committee • NHLBI SPIROMICS

Question #1: Which of the following is NOT true?

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A. COPD mortality has plateaued 54% B. Hospitalization for exacerbation predicts mortality C. Most exacerbations are caused by 25% infection 14% D. There are effective strategies for 7% decreasing exacerbations

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Update on the Management of COPD

NHLBI AsthmaNet

H o sp ita liz

Advances in Internal Medicine San Francisco, CA June 26, 2015

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CO P D

Stephen C. Lazarus, M.D. Division of Pulmonary & Critical Care Medicine Cardiovascular Research Institute University of California San Francisco

1

Leading Causes of Deaths in U.S. 2011 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Cause of Death

Heart Disease Cancer Respiratory Diseases (COPD) Stroke Accidents Alzheimer’s Diabetes Influenza & Pneumonia Kidney Disease Suicide All other causes of death

Number

596,577 576,691 142,943 128,932 126,438 84,974 73,831 53,826 45,591 39,518 646,137

Death in the US 2011, CDC, last updated 15 March, 2013

Percent Change in Age-Adjusted Death Rates (US, 1965–1998)

Proportion of 1965 Rate

3.0 2.5

CHD

Stroke

Other CVD

COPD

All other causes

2.0 1.5 1.0 0.5 0.0

–59%

1965 – 1998

–64%

1965 – 1998

–35%

1965 – 1998

+163%

1965 – 1998

–7%

1965 – 1998

COPD Exacerbations

COPD Exacerbations (AECOPD): The Major Complication of COPD

• “Exacerbations are to COPD what myocardial infarctions are to coronary artery disease”

• Characterized by episodic increases in dyspnea, sputum production and cough

• “They are the acute, often trajectorychanging, and sometimes deadly manifestations of a chronic disease”

• 16 million office visits/year

- Gerard J Criner, MD Temple University School of Medicine Philadelphia, PA, USA

• 500,000 hospitalizations/year • 110,000 deaths/year Mannino et al. MMWR Surveill Summ 2002; 51:1-16 NHLBI: http://www.nhlbi.gov/resources/docs/02_chtbk.pdf

2

Risk Factors for Frequent Exacerbations • Increased Age

• $18 billion in direct health care costs

• Severity of FEV1 Impairment

• Most patients experience a transient or permanent decrease in Quality Of Life

• Chronic mucus hypersecretion • Frequent past Exacerbations

• 50% are readmitted to the hospital within 6 months

• Daily cough and wheeze • Persistent symptoms of chronic Anzueto, Sethi, Martinez bronchitis

Miravitlles et al: Thorax 2004; 59:387-395

FEV1/FVC < 0.70

GOLD 1: (Mild COPD)

GOLD 2: (Moderate COPD) GOLD 3: (Severe COPD)

COPD Assessment: A New Model When assessing risk, choose the highest risk according to GOLD grade or exacerbation history

Risk GOLD Classification of Airflow Limitation

GOLD (2007) Classification of COPD Severity

Proc Am Thorac Soc 4:554-564, 2007

4 3

FEV1 > 80% predicted

FEV1 50-80% predicted

FEV1 30-50% predicted

GOLD 4: (Very Severe COPD) FEV1 40 ml/yr

FEV1 20 ml/yr

Vestbo et al, ECLIPSE N Engl J Med 365:1184-92, 2011

Effect of Corticosteroids on Expiratory Airflows in AE COPD Change in FEV1 from Day 1 (%)

Changes in FEV1 over time in COPD

Anthonisen et al Ann Intern Med 2005; 142:233-239

60

Prednisone 60qd x 3d, 40qd x 3d, 20qd x 3d Placebo #

50 40 30

*

20 10 0 -10

* = p7.35 • NIPPV ≥6 hrs overnight; titrated in hosp at BL and Q3 months.

• All-cause mortality at 1 year: NIPPV – 12% Control – 33% HR 0.24 (95% CI 0.11-0.29; p