Management of COPD & Asthma Melissa Brittle & Jessica Macaro.
Gerichte therapie bij Astma COPD overlap syndroom · 3 Achtergrond • Asthma vs. COPD Asthma COPD...
Transcript of Gerichte therapie bij Astma COPD overlap syndroom · 3 Achtergrond • Asthma vs. COPD Asthma COPD...
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Dr. Tobias Bonten
AIOS Huisartsgeneeskunde, Postdoc en Epidemioloog
Longziekten en Public Health & Eerstelijns Geneeskunde
LEIDS UNIVERSITAIR MEDISCH CENTRUM
Gerichte therapie bij Astma COPD overlap syndroom
(potentiële) belangenverstrengeling Geen
Disclosure belangen spreker
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GERICHTE BEHANDELING
9-Feb-173
Achtergrond
• Astma vs. COPD
9-Feb-174
Astma COPD
Risico factor Atopie (allergie) Roken / luchtverontreiniging
Leeftijd Alle (meestal begin<20)
Meestal >40
Symptomen
Hoesten Ja Ja
Slijm Niet vaak Vaak
Adem geluiden Piepen Piepen, gereutel
Kortademigheid Wisselend Persisterend(exacerbaties)
Prognosis Stabiel, normalelevensverwachting
Progressief, verminderdelevensverwachting
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Achtergrond
• Asthma vs. COPD
Asthma COPD
Diagnose
Laboratorium Allergie(IgE, eosinophielen)
Geen
Pulmonary function Normaal of reversibele obstructie
Irreversibeleobstructie
Achtergrond
• Astma EN COPD? Astma COPD overlap syndroom (ACOS)
?
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ACOS ?
2. Australian Asthma management HandbookPooling of features corresponding to asthma and COPD, followed by a trial of Inhalation Corticosteroids
1. GINA/GOLD (guideline)List 9 features: similar number of asthma and COPD features ACOS more likely; spirometry recommended
3. Japanese Respiratory Society COPD guidelinesAsthma component: paroxysmal dyspnoea, cough and wheeze worse at night and early morning, atopy, sputum/blood eosinophilia.
4. Spanish COPD consensus document- Major criteria:
- Increase FEV1 ≥ 15% and ≥400ml- Eosinophilia- History of asthma
- Minor criteria:- Total IgE- Atopy- ≥2 ocassions: FEV1 ≥ 12% and ≥200ml
ACOS if 2 major 1 major + 2 minor
5. Czech Pneumological and Physiological Society- Major criteria:
- Increase FEV1 ≥ 15% and ≥400ml- Positive provocation test- FeNO ≥ 45-50 ppb and/or sputum eosinophils ≥3%- History of asthma
- Minor criteria:- FEV1 ≥ 12% and ≥200ml- Total IgE- Atopy and COPD diagnosis
ACOS if 2 major 1 major + 2 minor
Gibson PG, et al. Thorax 2015
ACOS fenotypen…?
Bateman, Lancet Respir Med 2015
CHAOS instead of ACOS?
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Overzicht
1. Is ACOS klinisch relevant?
2. Hoe vaak komt ACOS voor?
3. Identificeren van ACOS in de eerste lijn
4. Adviezen over behandeling van ACOS
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Overzicht
1. Is ACOS klinisch relevant?
2. Hoe vaak komt ACOS voor?
3. Identificeren van ACOS in de eerste lijn
4. Adviezen over behandeling van ACOS
9-Feb-1710 Insert > Header & footer
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ACOS – klinisch relevant?
Nielsen M, et al. Int J COPD 2015
Frequency of exacerbations among ACOS patients is higher than in Asthma or COPD
ACOS – klinisch relevant? Eigen onderzoek bij 864 patienten met Astma/COPD
1. COPD AND Asthma in registry
2. COPD AND Asthma in registry OR ACOS as text in EMR
3. Self-reported COPD AND Asthma
4. FEV1/FVC < 0.7 AND ≥10 pack-years AND asthma <40 years
5. COPD in registry OR self-reported + FEV1/FVC < 0.7
AND
Asthma in registry OR Self-reported
6. COPD in registry OR Self-reported + FEV1/FVC < 0.7
AND
Asthma in registry OR Self-reported OR FENO ≥ 45 ppb
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ACOS – klinisch relevant?
• 864 patiënten met Astma/COPD
• Follow-up 1.8jr
• Exacerbatie: voorschrift corticosteroid of antibioticum door huisarts
* adjusted for: age, sex, bmi, current smoking, FEV1/FVC ratio at baseline, ICS use, number of exacerbations in previous year
ACOS – klinisch relevant?
* adjusted for: age, sex, bmi, current smoking, FEV1/FVC ratio at baseline, ICS use, number of exacerbations in previous year
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Survival is worse among ACOS patients than in Asthma or COPD, depending on age of asthma onset
Lange P, Lancet Resp Med 2016
ACOS – klinisch relevant?
ACOS – relevant for society?
Gerhardsson de Verdier M, Val Health 2015
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Overzicht
1. Is ACOS klinisch relevant?
2. Hoe vaak komt ACOS voor?
3. Identificeren van ACOS in de eerste lijn
4. Adviezen over behandeling van ACOS
9-Feb-1717 Insert > Header & footer
Eerdere studies Karakteristieken en ACOS prevalentie
Study Population Age Prevalence (%) Definition
Brzostek Smoking >45 100 Doctor diagnosed asthma + COPD
Fu Asthma, COPD, ACOS
>55 55.5 Symptoms, flow variability, incomplete reversible obstruction
Lee Asthma, ACOS 41-79 37.9 Asthma with incomplete reversible obstruction
Milanese Asthma ≥65 28.8 Asthma and chronic bronchitis and/or impaired diffusion
Miravitles COPD, ACOS 40-80 17.7 COPD (FEV1/FVC <0.7) and doctor diagnosed asthma <40yr
Kauppi Asthma, COPD, ACOS
18-75 14.5 Doctor diagnosed asthma + COPD (FEV1/FVC <0.7)
Hardin COPD, ACOS 45-80 12.6 COPD with self-reported asthma <40yr
de Marco General 20-84 1.6-4.5 Doctor diagnosed asthma + COPD
Pleasants General 18-74 3.3 Self-reported COPD and asthma
Chung General >19 2.3 FEV1/FVC <0.7 + self-reported wheezing history
Menezes General >40 1.8 Asthma (symptoms+spirometry / self-reported) and COPD (FEV1/FVC <0.7)
Nielsen M, et al. Int J COPD 2015
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Eerdere studies Karakteristieken en ACOS prevalentie
Study Population Age Prevalence (%) Definition
Brzostek Smoking >45 100 Doctor diagnosed asthma + COPD
Fu Asthma, COPD, ACOS
>55 55.5 Symptoms, flow variability, incomplete reversible obstruction
Lee Asthma, ACOS 41-79 37.9 Asthma with incomplete reversible obstruction
Milanese Asthma ≥65 28.8 Asthma and chronic bronchitis and/or impaired diffusion
Miravitles COPD, ACOS 40-80 17.7 COPD (FEV1/FVC <0.7) and doctor diagnosed asthma <40yr
Kauppi Asthma, COPD, ACOS
18-75 14.5 Doctor diagnosed asthma + COPD (FEV1/FVC <0.7)
Hardin COPD, ACOS 45-80 12.6 COPD with self-reported asthma <40yr
de Marco General 20-84 1.6-4.5 Doctor diagnosed asthma + COPD
Pleasants General 18-74 3.3 Self-reported COPD and asthma
Chung General >19 2.3 FEV1/FVC <0.7 + self-reported wheezing history
Menezes General >40 1.8 Asthma (symptoms+spirometry / self-reported) and COPD (FEV1/FVC <0.7)
Nielsen M, et al. Int J COPD 2015
Eigen onderzoek bij 864 patienten met Astma/COPD
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Prevalence
Total population
Asthma/COPDpopulation
ACOS Definition n = 5647 n = 846
1 COPD AND Asthma in registry 1.2 10.3
2 COPD AND Asthma in registry OR ACOS as text in EMR 1.2 10.3
3 Self-reported COPD AND Asthma 0.5 4.4
4 FEV1/FVC < 0.7 AND ≥10 pack-years AND asthma <40 years 0.6 4.7
5 COPD in registry OR self-reported + FEV1/FVC < 0.7 AND
Asthma in registry OR Self-reported
1.1 9.1
6 COPD in registry OR Self-reported + FEV1/FVC < 0.7 AND
Asthma in registry OR Self-reported OR FENO ≥ 45 ppb
4.9 38.2
Bonten TN et al: Defining Asthma COPD overlap syndrome: a population based study. ERJ 2017, accepted for publication
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Overzicht
1. Is ACOS klinisch relevant?
2. Hoe vaak komt ACOS voor?
3. Identificeren van ACOS in de eerste lijn
4. Adviezen over behandeling van ACOS
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ACOS ?
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Simpeler oplossing?Bij patiënten met COPD
ACOS 1: Spaanse consensus criteria
versus
ACOS 2: Alleen astma < 40 jaar, diagnosed only on the basis of a history of
asthma before the age of 40 years
Barrecheguren, Int J COPD 2015
Prevalentie
Barrecheguren, Int J COPD 2015
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ConclusieSimpeler oplossing voor eerste lijn?
Patients diagnosed with ACOS in COPD on the basis of a previous diagnosis of
asthma before the age of 40 years are very similar to patients diagnosed with
ACOS by the more restrictive criteria proposed by the Spanish consensus.
Therefore, the previous diagnosis of asthma before 40 years of age in a patient
with COPD can be used as a presumptive diagnosis of ACOS.
Barrecheguren, Int J COPD 2015
Overzicht
1. Is ACOS klinisch relevant?
2. Hoe vaak komt ACOS voor?
3. Identificeren van ACOS in de eerste lijn
4. Adviezen over behandeling van ACOS
9-Feb-1726 Insert > Header & footer
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ACOS – relevant voor behandeling?Timing van ICS
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STEP 1 STEP 2STEP 3
STEP 4
STEP 5
Low dose ICS
Consider low
dose ICS Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
As-needed short-acting beta2-agonist (SABA)
Low dose
ICS/LABA*
Med/high
ICS/LABA
Refer for add-on
treatment e.g.
anti-IgE
Add tiotropium#
High dose ICS
+ LTRA
(or + theoph*)
Add tiotropium#Add low dose OCS
As-needed SABA or low dose ICS/formoterol**
COPD: ICS= step 3
Asthma: ICS= step 1-2
GINA-GOLD
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GINA-GOLD: treatment ACOS
Initial treatment:
- Patients with features of asthma: receive adequate controller
therapy including inhaled corticosteroids, but not long-acting
bronchodilators alone (as monotherapy)
- Patients with features of COPD: receive appropriate
symptomatic treatment with bronchodilators or combination
therapy, but not inhaled corticosteroids alone (as
monotherapy).
www.ginaasthma.org
Hoe behandelen NL huisartsen patiënten met ACOS?
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Bonten TN et al: Defining Asthma COPD overlap syndrome: a population based study. ERJ 2017, accepted for publication
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Characteristic COPD in registry+
Asthma in registry
COPD in registry+
Asthma in registry
OR
ACOS as text in electronic record
COPD self-reported
+ Asthma
self-reported
FEV1/FVC < 0.7 +
≥10 pack-years+
asthma <40 years
COPD in registry OR
Self-reportedAND
FEV1/FVC < 0.7 +
Asthma in registry OR
Self-reported
COPD in registry OR
Self-reported OR
FEV1/FVC < 0.7 +
Asthma in registry OR
Self-reported OR
FENO ≥ 45
Medication use
SABA 15 15 29 42 22 20
LABA 6 6 6 0 1 4
LAMA 13 13 17 6 15 9
ICS 13 13 18 33 23 15
Combination LABA+ICS
45 45 56 38 48 40
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Take home messages
1. Is ACOS klinisch relevant? Hogere kans op exacerbaties dan
astma patiënten, hogere mortaliteit
2. Hoe vaak komt ACOS voor? ± 10% in 1e lijns astma/COPD
populatie
3. Identificeren van ACOS in de eerste lijn: voorgeschiedenis van
astma/symptomen bij COPD’er, bij hoge ziektelast verwijzen
naar longarts voor diagnostiek
4. Adviezen over behandeling van ACOS: ICS afhankelijk van
klachtenpatroon. Eenmalige verwijzing naar longarts voor
diagnostiek en behandeladvies?
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DankwoordLeiden University Medical Center study team
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Prof. Niels Chavannes
Prof. Christian Taube
Dr. Marise Kasteleyn
Prof. Pieter Hiemstra
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Evt. extra slides
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Defining ACOS – Patient examples
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Postma DS, Rabe KF. N Engl J Med 2015;373:1241-1249.
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Defining ACOS
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Postma DS, Rabe KF. N Engl J Med 2015;373:1241-1249.