Recent Advances in COPD MANAGEMENT RTM.pptx

COPD 2025

1. Recent Advances in COPD Management Dr. Nandani Gulati Senior Consultant Pulmonology, Critical care and Sleep Medicine Fortis Hospital Vasant Kunj and Gurgaon

2. COPD Burden Bajpai et al 5 : 57% of nonsmoker COPD patients were categorized as grade B COPD while 80% of smokers had group D COPD Suboptimal adherence to medication in COPD is common 6 1. Alqahtani JS et al. Plos one. 2022 May 19;17(5):e0268772. 2. Adeloye D et al. Lancet Respiratory Medicine. 2022 Mar 10; 2 3. Roy MP.. Clinical Epidemiology and Global Health. 2020 Sep 1;8(3):939-42.

3. Importance of exacerbations “ Frequent Exacerbator” Poorer Quality of Life Higher Mortality Faster Decline in Lung Function Greater Airway Inflammation Frequent exacerbators exists across all grades of GOLD 3-4 Risk of mortality increases with every exacerbation 1. Vanfleteren LEGW et al. ERJ Open Res. 2019;5(2):00235-2018. 2. Le Rouzik. et al. Chest. 2018;153(5):1106–1115. 3. Wedzicha et al. BMC Medicine 2013, 11:181. 4. Hurst JR et al. N Engl J Med. 2010;363(12):1128–1138.

4. COPD: Problem Statement 1.Db Jyothi et al Maedica ( Bucur ). 2020 Mar; 15(1): 37–44, 2. Hurst JR et al. Eur J Intern Med. 2020;73:1-6 3. Koul PA et al. Lung India. 2017 Nov-Dec;34(6):511-516, 4. Bhome AB et al. J Thorac Dis. 2012 Jun 1; 4(3): 298–309, 5. Gaude GS et al. Lung India. 2015 Sep-Oct;32(5):465-72, 6. Anzueto A.. European Respiratory Review. 2010 Jun 1;19(116):113-8

5. Key points GOLD 2025 © 2022 Global Initiative for Chronic Obstructive Lung Disease

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15. Case 1 71 year Female, Biomass exposure (>40 years) complaint of increasing SOB on exertion 4 year h/o SOB, No h/o exacerbation in past 4 years No cough/sputum Medical history Osteoporosis Compression fracture Rheumatic fever Current treatment by GP SABA as needed Case 1

16. Case 1 …(cont.) Spirometry FEV1/FVC 60% FEV1 63% Workup CAT score = 10 mMRC dyspnea score = 2 Decreased breath sounds No wheezing/rales Case 1

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19. Based on the GOLD recommendation, which of the following treatments would be the best option for this patient? Continue current treatment LABD monotherapy Start Dual bronchodilator - LABA/LAMA Case 1

20. Based on the GOLD recommendation, which of the following treatments would be the best option for this patient? Continue current treatment LABD monotherapy Start Dual bronchodilator - LABA/LAMA Case 1

21. Case 2 64 year Male, Ex-smoker with progressive shortness of breath (SOB) and scanty daily cough Chief complaints SOB requiring stopping while on level ground Intermittent discolored sputum No weight loss, fever, sweat, edema COPD, FEV1 45% Medical history “Bronchitis’ episode last year that required hospitalization CAP 3 years ago HTN, Osteopenia Case 2

22. Case 2 …(cont.) Social history 1 pack/day for 35 years; quit smoking 5 years ago Medications Sal-Flu 500 inhaler Diltiazem, Lisinopril Lab tests Hb 14 g/ dL , Hct 44% WBC 8000/mL, Eosinophil 2% CAT score = 18 mMRC dyspnea score = 3 Physical examination Decreased breath sounds Case 2

23. Based on the GOLD recommendation, which of the following treatments would be the best option for this patient? Deescalate to ICS dose Continue current treatment Shift to Dual bronchodilator - LABA/LAMA Escalate to Triple therapy - ICS/LABA/LAMA Case 2

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27. What should be the treatment? Continuation of LAMA Dual therapy - LABA/LAMA FDC Dual therapy - ICS/LABA FDC Triple therapy – ICS/LABA/LAMA Case 3

28. Case 4 70 Yr, Male. K/C/O COPD Chief complaint Increasing SOB on exertion since 3 months ”Clears his chest” every morning and think it may be getting worse Medical H/O Rheumatoid Arthritis, Dementia No H/O exacerbation in past 1 year FEV1 = 56%, FEV1/FVC = 0.62 CAT score = 15, mMRC score = 3 Blood eosinophils = 2% Currently on Tiotropium pMDI Salbutamol inhaler as reliever Case 4

29. What change in the current treatment you would like to suggest? Change to Glyco nebulization Change to Glyco/For nebulization Change to LABA/LAMA pMDI Change to ICS/LABA pMDI Case 4

30. Elderly Has Many Issues in Inhalation Therapy Use Usmani O et al. Therapeutics and Clinical Risk Management 2019:15 461–472

31. Suboptimal PIFR is key concern in elderly COPD pts Author, Yr. Number Mean PIFR L/Min (±SD) % pts < 60 L/min Al Showair , 2007 163 57 ± 18 53% Janssens, 2008 26 NA 36% Mahler, 2013 213 71 ± 26 19% Duarte, 2019 303 65 ± 11 20% Prevalence of sPIFR (<60 L/min) in COPD pts Prevalence of sPIFR (<60 L/min) in hospitalized pts for AECOPD

32. From Ease Of Preparation To Ease Of Inhalation DPI MDI BA pMDI pMDI ± spacer pMDI + spacer Nebuliser Easy to prepare but hard to inhale correctly Easy to inhale but hard to prepare correctly Modified from Lavorini et al. Drugs Aging. 2016. DOI: 10.1007/s40266-016-0377-y Likely patient profile Young Clinically Stable Maintenance Rx Good Hand-Lung coordination Elderly Clinically unstable/Hosp. Exacerbation/Maintenance Rx Poor Hand-Lung coordination DPI pMDI Neb

33. On Nebulizers in COPD, Patients are Happy 89% patients and 92% caregivers : generally satisfied with current nebulized treatment 80% patients and caregivers : using nebulizer was easier than an inhaler 79% patients and 85% caregivers : benefits outweigh its difficulties 75% patients : QoL improved since starting nebulisation 77% patients : nebulisation enabled the caregiver to provide better care

34. Nebulized Gly is Safer than Tio in CV risk patients Randomized, open-label, active-controlled study 1050 Mod to Very Severe COPD with Cardiac comorbidities High-risk Cardiac COPD: Pts with ≥2 risk factors for CVD (IHD, MI ± Heart failure) Low-risk Cardiac COPD: Pts with <2 risk factors for CVD (Hypertension) Results GLY was safer in ‘High risk Cardiac COPD’ TIO rate of CV events and MACE were higher among patients not receiving background LABAs Ferguson GT. Chronic Obstr Pulm Dis 2019;6(1):86-99.

35. What change in the current treatment you would like to suggest? Change to Glyco nebulization Change to Glyco/For nebulization Change to LABA/LAMA pMDI Change to ICS/LABA pMDI Case 4

36. Thank You !!