De presentatie wordt gedownload. Even geduld aub

De presentatie wordt gedownload. Even geduld aub

COPD: wat is er nieuw? V. Nowé. Topics Begin: = oud (GOLD 2011) Wat is er naast GOLD? – GOLD C – D: iedereen IHC? Effect op exacerbaties? Pneumonie? Dosis.

Verwante presentaties


Presentatie over: "COPD: wat is er nieuw? V. Nowé. Topics Begin: = oud (GOLD 2011) Wat is er naast GOLD? – GOLD C – D: iedereen IHC? Effect op exacerbaties? Pneumonie? Dosis."— Transcript van de presentatie:

1 COPD: wat is er nieuw? V. Nowé

2 Topics Begin: = oud (GOLD 2011) Wat is er naast GOLD? – GOLD C – D: iedereen IHC? Effect op exacerbaties? Pneumonie? Dosis IHC? Afbouwen mogelijk en bij wie? – Azithromycine: wie? Nieuwe inhalatoren Pneumococcenvaccin Acetylcysteïne

3 GOLD COPD aanpak/behandeling: Doel: – Symptomen verminderen (Korte termijn) – Verminderen van exacerbaties/hospitalisaties (Lange termijn) Exacerbaties/hospitalisatie Sneller achteruitgang Lf Gedaalde fysische activiteit/inspanningstoleran tie Gedaalde QOL Verhoogd risico op overlijden a five-year mortality rate of about 50%

4 GOLD Aanpassing – 2001: COPD obv ernst (FEV1): stadia I-IV

5

6 GOLD Aanpassing – 2001: COPD obv ernst (FEV1): stadia I-IV – 2011: FEV1 niet betrouwbare marker voor ernst van symptomen (dyspnoe, inspanningsbeperking, exacerbatierisico, hospitalisatierisico, overlijden) --> GOLD klassen A-B-C-D – 2013,2014 en 2015 updates

7 GOLD 2015: klassen – Symptomen – Risico’s op exacerbaties – Ernst longfunctie afwijkingen GOLD 2015: therapie – Klasse – Comorbiditeit

8 ECLIPSE: Verhoogd risico op exacerbaties: heterogeniteit

9 ECLIPSE

10 In eerste jaar vd studie 29% Geen exa in 3 jaar Geen exa in voorgaand e jaar Sterk geassocieerd met exa in voorafgaande jaar

11 Exacerbations per year 0 CAT < 10 mMRC 0-1 GOLD 4 CAT > 10 mMRC > 2 GOLD 3 GOLD 2 GOLD 1 SAMA prn or SABA prn LABA or LAMA ICS + LABA or LAMA Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy RECOMMENDED FIRST CHOICE A B DC ICS + LABA and/or LAMA © 2014 Global Initiative for Chronic Obstructive Lung Disease 2 or more or > 1 leading to hospital admission 1 (not leading to hospital admission) GOLD

12 Symptomen

13 Global Strategy for Diagnosis, Management and Prevention of COPD Modified MRC (mMRC)Questionnaire © 2014 Global Initiative for Chronic Obstructive Lung Disease

14 Global Strategy for Diagnosis, Management and Prevention of COPD Assess Risk of Exacerbations To assess risk of exacerbations use history of exacerbations and spirometry:  Two or more exacerbations within the last year or an FEV 1 < 50 % of predicted value are indicators of high risk.  One or more hospitalizations for COPD exacerbation should be considered high risk. © 2014 Global Initiative for Chronic Obstructive Lung Disease GOLD

15  Appropriate pharmacologic therapy can reduce COPD symptoms, reduce the frequency and severity of exacerbations, and improve health status and exercise tolerance.  None of the existing medications for COPD has been shown conclusively to modify the long-term decline in lung function.  Influenza and pneumococcal vaccination should be offered depending on local guidelines.  Smoking cessation Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Key Points GOLD

16  Bronchodilator medications are central to the symptomatic management of COPD.  Bronchodilators are prescribed on an as-needed or on a regular basis to prevent or reduce symptoms.  The principal bronchodilator treatments are beta 2 - agonists, anticholinergics, theophylline or combination therapy.  The choice of treatment depends on the availability of medications and each patient’s individual response in terms of symptom relief and side effects.. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Bronchodilators © 2014 Global Initiative for Chronic Obstructive Lung Disease GOLD

17  Regular treatment with inhaled corticosteroids improves symptoms, lung function and quality of life and reduces frequency of exacerbations for COPD patients with an FEV 1 < 60% predicted.  Inhaled corticosteroid therapy is associated with an increased risk of pneumonia.  Withdrawal from treatment with inhaled corticosteroids may lead to exacerbations in some patients. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Inhaled Corticosteroids GOLD

18 Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Non-pharmacologic Patient Group EssentialRecommendedDepending on local guidelines A Smoking cessation (can include pharmacologic treatment) Physical activity Flu vaccination Pneumococcal vaccination B, C, D Smoking cessation (can include pharmacologic treatment) Pulmonary rehabilitation Physical activity Flu vaccination Pneumococcal vaccination © 2014 Global Initiative for Chronic Obstructive Lung Disease

19 Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy ( Medications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference.) PatientRecommendedFirs t choice Alternative choiceOther Possible Treatments A SAMA prn or SABA prn LAMA or LABA or SABA and SAMA Theophylline B LAMA or LABA LAMA and LABA SABA and/or SAMA Theophylline C ICS + LABA or LAMA LAMA and LABA or LAMA and PDE4-inh. or LABA and PDE4-inh. SABA and/or SAMA Theophylline D ICS + LABA and/or LAMA ICS + LABA and LAMA or ICS+LABA and PDE4-inh. or LAMA and LABA or LAMA and PDE4-inh. Carbocysteine SABA and/or SAMA Theophylline

20 Oxygen: titrate to improve the patient’s hypoxemia with a target saturation of 88-92%. Bronchodilators: Short-acting inhaled beta 2 -agonists with or without short-acting anticholinergics are preferred. Systemic Corticosteroids: Shorten recovery time, improve lung function (FEV 1 ) and arterial hypoxemia (PaO 2 ), and reduce the risk of early relapse, treatment failure, and length of hospital stay. A dose of 40 mg prednisone per day for 5 days is recommended. Nebulized magnesium as an adjuvent to salbutamol treatment in the setting of acute exacerbations of COPD has no effect on FEV 1. Global Strategy for Diagnosis, Management and Prevention of COPD Manage Exacerbations: Treatment Options © 2014 Global Initiative for Chronic Obstructive Lung Disease

21 Wat weten we naast GOLD?

22 LAMA or LABA SAMA or SAAB SOS 1)ICS + LABA or LAMA 2)ICS + LABA + LAMA Symptoms (mMRC or CAT score) Risk (Exacerbation history) Spirometry (GOLD Classification of Airflow Limitation) ≥ 2 mMRC < 2 CAT < 10 mMRC ≥ 2 CAT ≥ 10 Management of COPD according to Symptoms, Spirometric classification and Future Risk of Exacerbations

23  Bronchodilator medications are central to the symptomatic management of COPD.  Bronchodilators are prescribed on an as-needed or on a regular basis to prevent or reduce symptoms.  The principal bronchodilator treatments are beta 2 - agonists, anticholinergics, theophylline or combination therapy.  The choice of treatment depends on the availability of medications and each patient’s individual response in terms of symptom relief and side effects.. Global Strategy for Diagnosis, Management and Prevention of COPD Therapeutic Options: Bronchodilators © 2014 Global Initiative for Chronic Obstructive Lung Disease GOLD

24

25 Effect of ICS on exacerbations (moderate and severe) Mean number of exacerbations/year 1,13 0,97 * 0,93 * 0,85 * †‡ 17% reduction 0 0,2 0,4 0,6 0,8 1 1,2 PlaceboSALMFPSALM/FP Calverley P. et al. NEJM 2007.

26 Exacerbations requiring hospital admission Mean number of severe exacerbations/year 0,19 0,16 * 0,17 0,16 † 0 0,05 0,1 0,15 0,2 0,25 PlaceboSALMFPSALM/FP Calverley P. et al. NEJM 2007.

27 In COPD, hoe verhoudt zich het risico van ICS tov het voordeel van ICS? A.NNH << NNT B.NNH < NNT C.NNH = NNT D.NNH > NNT E.NNH >> NNT NNH: Number Needed to Harm NNT: Number Needed to Treat

28 In COPD, hoe verhoudt zich het risico van ICS tov het voordeel van ICS? A.NNH << NNT B.NNH < NNT C.NNH = NNT D.NNH > NNT E.NNH >> NNT NNH: Number Needed to Harm NNT: Number Needed to Treat

29 ______________

30 ICS in COPD: risk of pneumonias Suissa S., Thorax = NNH

31 ICS in COPD: risk of pneumonia Price D. et al, PCRJ 2013.

32 Wat is de optimale dosis ICS bij COPD? A.Budesonide 2x 400 = 800 µg B.Fluticason dipropionaat 2x 100 = 200 µg C.Fluticason dipropionaat 2x 250 = 500 µg D.Fluticason dipropionaat 2x 500 = µg E.Fluticason furoaat 1x 50 = 50 µg F.Fluticason furoaat 1x 92 = 92 µg G.Fluticason furoaat 1x 184 = 184 µg

33

34

35 Wat is de optimale dosis ICS bij COPD? A.Budesonide 2x 400 = 800 µg ? B.Fluticason dipropionaat 2x 100 = 200 µg C.Fluticason dipropionaat 2x 250 = 500 µg ? D.Fluticason dipropionaat 2x 500 = µg E.Fluticason furoaat 1x 50 = 50 µg F.Fluticason furoaat 1x 92 = 92 µg G.Fluticason furoaat 1x 184 = 184 µg

36 In patiënten met COPD * leidt stoppen van ICS tot: A.Exacerbaties B.Frequente exacerbaties C.Mortaliteit D.Depressie E.Geen van bovenstaande antwoorden * behandeld met tripple therapie (LAMA + LABA + ICS)

37 In patiënten met COPD * leidt stoppen van ICS tot: A.Exacerbaties B.Frequente exacerbaties C.Mortaliteit D.Depressie E.Geen van bovenstaande antwoorden * behandeld met triple therapie (LAMA + LABA + ICS)

38 WISDOM trial _____

39 WISDOM trial: exacerbations Magnussen H. et al, NEJM 2014.

40 Volgens GOLD Withdrawal from treatment with inhaled corticosteroids may lead to exacerbations in some patient, although in another study with severe and very severe COPD patients, inhaled corticosteroids could be gradually withdrawn over a three-month period without increasing the medium term risk of exacerbations, although lung function deteriorated significantly.

41 The ‘frequent exacerbator phenotype’: ECLIPSE Frequency/Severity of Exacerbations by GOLD stage Hurst JR, et al. N Engl J Med. 2010;363: Exacerbation rates increased with GOLD stage, irrespective of severity of exacerbation.

42 Acute exacerbations of COPD: heterogeneity Bafadhel M. et al, AJRCCM 2011; 184:

43

44 COPD exacerbation type predicts response to azithromycin M. Han et al, AJRCCM 2014.

45

46 Azithromycin prevents exacerbations of COPD Albert R. et al, NEJM 2011.

47

48 SABA ± SAAC SOS Maintenance: LAMA or LABA Maintenance: LAMA and LABA Maintenance: LAMA and LABA Plus: 1)ICS and/or 2) AZI Smoking cessation Vaccination (influenza) Patient education Self-management Pulmonary rehabilatation: if mMRC ≥ 2 Oxygen therapy: if PaO2 < 60 mmHg STEP 1 Spiro 1 or 2 mMRC < 2 No exac STEP 2 Spiro 1 or 2 mMRC ≥ 2 ≤ 1 exac STEP 3 Spiro 3 or 4 ≤ 1 exac STEP 3 Spiro 3 or 4 ≤ 1 exac STEP 4 Spiro 2, 3 or 4 mMRC ≥ 2 ≥ 2 exac Reliever: SAMA or SABA Stepwise treatment of COPD according to Severity: spirometry, symptoms, exacerbations

49 Nieuwe inhalatoren Zie hand-outs

50 LAMA

51 ICS+LABA

52 LAMA+LABA

53 Pneumococcen vaccin? GOLD – Influenza vaccines can reduce serious illness. Pneumococcal polysaccharide vaccine is recommended for COPD patients 65 years and older and for COPD patients younger than age 65 with an FEV 1 < 40% predicted Hoge raad – Nieuwe publicatie 10/2/2015 – Aanpassingen obv Capita studie

54 OUDE RICHTLIJN

55

56

57

58

59 Acetylcysteïne GOLD 2015 – Hoge dosis NAC: significant minder exa in GOLD II Pantheon Lancet 2014

60 ObjectifsMéthodeRésultatsConclusions Resultaten 6 Notices PANTHEON-studie: The Lancet, 2014 Aantal exacerbaties per behandelingsperiode COPD-patiënten in GOLD-stadia II en III -22% 6. Zhen J-P, et al. Twice daily N-acetylcysteine 600 mg for exacerbations of chronic obstructive pulmonary disease (PANTHEON): a randomised, double-blind placebo-controlled trial. Lancet Respir Med Mar;2(3): ZambonGamme10 tabsMode d’action ObjectifsMéthodeRésultatsConclusionRésumé

61 ObjectifsMéthodeRésultatsConclusionsNotices 6. Zhen J-P, et al. Twice daily N-acetylcysteine 600 mg for exacerbations of chronic obstructive pulmonary disease (PANTHEON): a randomised, double-blind placebo-controlled trial. Lancet Respir Med Mar;2(3): PANTHEON-studie: The Lancet, 2014 Resultaten 6 Jaarlijks aantal exacerbaties per GOLD-stadium -39% VERBETERING VAN DE KLINISCHE TOESTAND VAN DE PATIËNT IN DE GOLD-STADIA II EN III NAC vermindert het jaarlijks aantal exacerbaties van COPD-patiënten in GOLD-stadium II (matig) met 39 % NAC 1200 mg vs Placebo - Gold Mod. < (0.48,0.77) ZambonGamme10 tabsMode d’action ObjectifsMéthodeRésultatsConclusionRésumé

62 Take home messages Nieuwe GOLD: leiddraad Maar in GOLD C en D – LAMA+LABA staan op de eerste plaats bij GOLD C-D – IHC pro’s en con’s Dosis te hoog? WISDOM: 1 jaar geen exacerbatie --> afbouwen = veilig – COLUMBUS: Azithromycine: >= 2-3 exa per jaar NAC in GOLD 2: significante daling van exacerbaties Pneumococcen vaccinatie: nieuwe aanbeveling van de Hoge Raad

63 Verdere studies nodig – predictoren voor IHC/azithromycine behandeling? Eosinofielen (referentie Brusselle) – > > IHC: 30% minder exacerbaties – IHC geen daling van exacerbaties, eerder meer pneumonieen Eerdere behandeling (cortico’s+AB) --> azi gevoelig Take home messages

64


Download ppt "COPD: wat is er nieuw? V. Nowé. Topics Begin: = oud (GOLD 2011) Wat is er naast GOLD? – GOLD C – D: iedereen IHC? Effect op exacerbaties? Pneumonie? Dosis."

Verwante presentaties


Ads door Google