ABC of COPD
Age >40 years
Breathing or dyspnea is: progressive (worsens over time), worsens with exercise, persistent
Chronic cough
Indicators of COPD diagnosis
- chronic sputum production
- tobacco smoke
- indoor pollution
- occupational dusts and chemicals
- family history of copd
spirometry results
fev1/fvc <0.70 confirms persistent airflow limitation
symptoms assessment for copd
- copd assessment test (cat)
- modified british medical research council (mmrc) breathlessness scale
- degree of airflow limitation
gold grading
gold 1, mild: fev >/= 80% predicted
gold 2, moderate 50% < fev1 < 80%
gold 3, severe 30 < fev1 < 50%
gold 4, very severe fev1 < 30%
risk assessment for exacerbations
abcd assessment tool read!!
moa of bronchodilators
- b2 agonist: stimulate b2 receptors to relax airway smooth muscle
- anticholinergics: blocks effect of acetylcholine on m3 receptors to relax smooth muscle
- methylxanthines: unknown moa
initial treatments by group
group a: bronchodilator
group b: laba or lama
group c: lama
group d: lama or lama + laba or ics + laba
what are sabas
- salbutamol and fenoterol
- fast onset with 4 to6 hour duration
- sedating
what are twice a day labas
- salmeterol, formoterol
- 12 hr duration
ultra once a day labas
- indacaterol, olodaterol, vilanterol, abediterol
- very fast acting, longer than 24 hour duration
- once daily dosing gets better adherence
what are lama/laba fixed dose combinations
- benefits of both laba and lama
lama: tiotropium, glycopyrronium, umeclidinium, aclidinium
lama/laba combinations
- glycopyrronium/ indacaterol
- umeclidinium/ vilanterol
- tiotropium/ olodaterol
- aclidinium/ formoterol
- glycopyrronium bromide/ formoterol
benefits of laba/lama
- better compliance
- greater improvements
- lower risk of side effects
considerations for corticosteroids
- long term monotherapy with ics not recommended
- long term oral steroids not recommended
- long term ics + laba can be considered for severe
considerations for pde-4 inhibitors
- roflumilast can reduce exacerbations for pts w: chronic bronchitis, severe/very severe airflow limitation, frequent exacerbations
- theophylline is a nonselective pde inhibitor
considerations for anti-inflammatory agents
- macrolides for former smokers with exacerbations
- antioxidant mucolytics for some patients
strong support to start ics treatment
- history of hospitalization/s for exacerbations of copd
- two or more moderate exacerbations of copd per year
- blood eosinophils > 300 cells/mcL
- history or concomitant asthma
consider use ics treatment
- 1 moderate exacerbation of copd per year
- blood eosinophils 100-300 cells/mcL
against use ics treatment
- repeated pneumonia events
- blood eosinophils <100 cells/mcL
- histroy of mycobacterial infection
follow up pharmacological treatment
read
