2020 10 09 Algorithms in Asthma and COPD.pptx

Algorithms in Asthma and COPD to support management from healthcare professionals

1. Algorithms in Asthma and COPD Konstantinos Kostikas MD, PhD, FCCP , FERS Assoc. Professor of Respiratory Medicine, University of Ioannina, Greece Head Respiratory Medicine Department, University Hospital of Ioannina, Greece Hon. Professor of Respiratory Medicine, Observational and Pragmatic Research Institute, Singapore e-mail: [email protected] , [email protected] https://respiratory-ioannina.com What is New in Respiratory Medicine https://www.facebook.com/groups/winrespmed #WiNRespMed

2. I was an employee and shareholder of Novartis Pharma AG until 31.10.2018 I have received honoraria for presentations and consultancy fees from AstraZeneca, Boehringer Ingelheim, Chiesi , ELPEN, GSK, Menarini, Novartis and Sanofi My department has received funding and grants from AstraZeneca, Boehringer Ingelheim, Chiesi , Innovis, ELPEN, GSK, Menarini, Novartis and NuvoAir I am a member of the GOLD Assembly Conflict of Interest Statement

3. The unmet needs of asthma: One-year follow up of asthmatic patients initiated on medium- or high-dose ICS/LABA in the UK Buhl R, … Kostikas K, et al, Respir Med 2020; 162, 105859

4. The unmet needs of asthma: One-year follow up of asthmatic patients initiated on medium- or high-dose ICS/LABA in the UK Buhl R, … Kostikas K, et al, Respir Med 2020; 162, 105859

5. Asthma diagnosis - GINA 2020 GINA 2020 © Global Initiative for asthma, www.ginasthma.com

6. Asthma control and risk factors - GINA 2020 GINA 2020 © Global Initiative for asthma, www.ginasthma.com

7. Asthma management - GINA 2020 GINA 2020 © Global Initiative for asthma, www.ginasthma.com

8. SYGMA 1: BUD/FORM as needed superior to SABA in asthma control (but inferior to low dose ICS) – with reduction in exacerbations Patients with week of well-controlled asthma BUD/FORM vs. SABA: 34.4% vs. 31.1% of weeks OR 1.14; 95%CI 1.00 to 1.30; P = 0.046 BUD/FORM vs. low dose BUD: 34.4% vs. 44.4% of weeks OR 0.64; 95% CI, 0.57 to 0.73 O'Byrne PM et al., N Engl J Med 2018;378:1865-76 Severe asthma exacerbations BUD/FORM vs. SABA: RR 0.36 (95% CI, 0.27 to 0.49) BUD/FORM vs. low dose BUD: 0.83 (95% CI, 0.59 to 1.16) Mean daily ICS dose BUD/FORM vs. low dose BUD: 57 μg vs. 340 μg ( 83% lower )

9. SYGMA 2: BUD/FORM as needed non inferior to low dose ICS on exacerbations (but inferior on asthma control - and lung function) Bateman ED et al., N Engl J Med 2018; 378:1877-87 Mean daily ICS dose BUD/FORM vs. low dose BUD: 66 μg vs. 267 μg ( 75% lower )

10. Initial choice of treatment - GINA 2020 GINA 2020 © Global Initiative for asthma, www.ginasthma.com

11. Initial choice of treatment - GINA 2020 GINA 2020 © Global Initiative for asthma, www.ginasthma.com

12. Asthma management - GINA 2020 ICS-formoterol is the preferred reliever for patients prescribed maintenance and reliever therapy. For other ICS-LABAs, the reliever is SABA GINA 2020 © Global Initiative for asthma, www.ginasthma.com

13. Triple FDC (ICS/LABA/LAMA) therapy in asthma Virchow JC, Lancet 2019; 394 (10210), 1737-1749; Kerstjens HAM et al, Lancet Respir Med 2020 Jul 9;S2213-2600(20)30190-9; Lee LA et al, Lancet Respir Med 2020 Sep 9;S2213-2600(20)30389-1 TRIGGER (BDP/FF/GG) PALLADIUM (MF/IND/GLY) CAPTAIN (FF/VI/UMEC)

14. Step down options in asthma - GINA 2020 GINA 2020 © Global Initiative for asthma, www.ginasthma.com

15. Difficulty confirming the diagnosis of asthma Persistent or severely uncontrolled asthma or frequent exacerbations Any risk factors for asthma-related death Near-fatal asthma attack (ICU admission, or mechanical ventilation for asthma) at any time in the past Hospitalization or emergency care visit for asthma in the past year Anaphylaxis or confirmed food allergy in a patient with asthma Currently using or having recently stopped using oral corticosteroids (a marker of event severity) Not currently using inhaled corticosteroids Over-use of SABAs, especially use of more than one canister of salbutamol (or equivalent) monthly A history of psychiatric disease or psychosocial problems Poor adherence with asthma medications and/or poor adherence with (or lack of) a written asthma action plan Food allergy in a patient with asthma Evidence of, or risk of, significant treatment side-effects Patients with significant side-effects from treatment Need for long-term oral corticosteroid use Frequent courses of oral corticosteroids (e.g. two or more courses a year) Symptoms suggesting complications or sub-types of asthma e.g. aspirin-exacerbated respiratory disease; allergic bronchopulmonary aspergillosis, EGPA etc. Suspected occupational asthma Indications for considering referral for expert advice - GINA 2020 Modified from GINA 2020 © Global Initiative for asthma, www.ginasthma.com

16. Severe asthma management - GINA 2020 GINA 2020 © Global Initiative for asthma, www.ginasthma.com

17. GOLD 2020: COPD Diagnosis © 2020 Global Initiative for Chronic Obstructive Lung Disease

18. GOLD 2020: Initial and Follow-Up Management © 2020 Global Initiative for Chronic Obstructive Lung Disease

19. LABA/LAMA vs. LABA/ICS for exacerbation prevention Wedzicha JA et al, N Engl J Med 2016; 374: 2222-2234; Calverley PMA, et al, Lancet Respir Med 2018; 6 (5): 337-344 FLAME DYNAGITO

20. Is there a place for LABA/ICS? Papi A, Kostikas K, et al. AJRCCM 2018 May 1;197(9):1223-1226 Rate ratios (95% CI) of moderate/severe chronic obstructive pulmonary disease exacerbations b.i.d ., twice daily; CI, confidence interval; IND/GLY, indacaterol/glycopyrronium; o.d ., once daily; RR, rate ratio; SFC, salmeterol/fluticasone

21. Triple therapy (LABA/LAMA/ICS) vs. LABA/LAMA on exacerbations Lipson DA, et al. N Engl J Med 2018; 378:1671 – 1680; Papi A et al. Lancet 2018; 391:1076 – 1084; Rabe KF et al, N Engl J Med 2020;383(1):35-48 TRIBUTE IMPACT ETHOS

22. The right treatment for the right patient with COPD: triple vs. LABA/LAMA (lessons from the IMPACT trial) Stolz D and Miravitlles M, Eur Respir J 2020; 55: 2000881

23. Withdrawal of inhaled corticosteroids in COPD: a European Respiratory Society guideline Chalmers JD et al, Eur Respir J 2020; 55: 2000351

24. ICS withdrawal in "stable" COPD patients (SUNSET) Rate of moderate or severe exacerbations (overall population) IND/GLY, indacaterol/glycopyrronium 1 10/50 μ g once daily; SFC, salmeterol/fluticasone propionate 50/500 μ g twice daily; TIO, tiotropium 18 μ g once daily Rate of moderate or severe exacerbations by baseline eosinophil counts Chapman K, …, Kostikas K, and Wedzicha JA, Am J Respir Crit Care Med 2018; 198:329–339

25. Management of COPD-Asthma Overlap Maselli DJ, et al. CHEST 2019; 155(1):168-177

26. Patients with features of asthma and COPD (ACO) GINA 2020 © Global Initiative for asthma, www.ginasthma.com

27. Monitoring in the digital era

28. Artificial intelligence (AI) outperforms pulmonologists in the interpretation of PFTs Topalovic M, et al., Eur Respir J 2019; 53: 1801660 74.4±5.9% 100% 44.6±8.7% 82% κ=0.67 κ=0. 35 AI, artificial intelligence; PFTs, pulmonary function tests; κ , interrater variability

29. The Asthma/COPD Differentiation Classification (AC/DC) diagnostic tool proposed application: Extreme Gradient Boosting (XGB) model Sensitivity refers to the fraction of patients who are correctly diagnosed by model as having COPD, asthma or ACO F1-score is a measure of a test’s accuracy AC/DC, Asthma/COPD Differentiation Classification; ACO, asthma-COPD overlap; BMI, body mass index; COPD, chronic obstructive pulmonary disease; FEV 1 , forced expiratory volume in 1 second, FVC, forced vital capacity; XGB, Extreme Gradient Boosting FEV 1 FEV 1 /FVC Pack Year Age BMI Dyspnea Wheeze Cough Diagnosis of allergic rhinitis Current smoker Never smoked Diagnosis of chronic rhinitis XGB model with 12 clinical features   Sensitivity F1-score ACO 0.78 0.84 Asthma 0.98 0.98 COPD 0.98 0.98 Kaplan A, … Kostikas K, et al, ATS 2020

30. AI in Asthma: a systematic review Exarchos KP, Beltsiou M, Votti C-A, and Kostikas K. Eur Respir J 2020; May 7; 2000521 AI, artificial intelligence

31. What is New in Respiratory Medicine #WiNRespMed #staysafe # spreadmusic_notvirus #mwstw_covid19