งานนำเสนอเรื่อง: "Reduce and Prevent exacerbation in COPD patients: Is it easy?"— ใบสำเนางานนำเสนอ:
1 Reduce and Prevent exacerbation in COPD patients: Is it easy? รศ. นพ. วัชรา บุญสวัสดิ์ M.D., Ph.D.ประธานเครือข่ายคลินิกโรคหืดและปอดอุดกั้นเรื้อรังแบบง่าย ภาควิชาอายุรศาสตร์ คณะแพทยศาสตร์ มหาวิทยาลัยขอนแก่น
3 Exacerbations Patients with frequent exacerbations Lower quality of lifeIncreased mortality rateIncreasedinflammationIncreased risk of recurrent exacerbationsSpeaker notesSome patients with COPD are susceptible to frequent exacerbations.1,2 Cohort studies have reported evidence of a phenotypic exacerbator,3 and other studies have reported differences in exacerbation rate despite similar FEV1 levels.4While exacerbation frequency is linked to disease severity, it is important to consider that not only patients with severe COPD are frequent exacerbators.2Exacerbations are associated with increased inflammation, which persists after the attack and affects the length of recovery period.5 In addition, patients who suffer from frequent exacerbations have increased airway inflammation in the stable state.6Frequent exacerbators display worse quality of life,1,7 faster decline in lung function,1,2,7 and higher mortality rates than patients with less frequent exacerbations.1,2,8,9Managing exacerbations, including reducing their frequency and severity, is a major goal of COPD disease management in the GOLD Global strategy for the diagnosis, management, and prevention of COPD.10ReferencesWedzicha JA and Seemungal TA. COPD exacerbations: defining their cause and prevention. Lancet. 2007;370:Donaldson GC and Wedzicha JA. COPD exacerbations: Epidemiology. Thorax 2006;61:Seemungal TAR, Hurst JR and Wedzicha JA. Exacerbation rate, health status and mortality in COPD – a review of potential interventions. Int J COPD 2009;4:Kim V, Han MK, Vance GB, et al. Chronic bronchitic symptoms are associated with worse symptoms and greater exacerbation frequency in COPD. Am J Respir Crit Care Med 2010;181:A1533.Perera W, Hurst JR, Wilkinson TM, et al. Inflammatory changes, recovery and recurrence at COPD exacerbation. Eur Respir J 2007;29:Bhowmilk A, Seemungal TA, Sapsford RJ, et al. Relation of sputum inflammatory markers to symptoms and lung function changes in COPD exacerbations. Thorax 2000;55:Decramer M, Celli B, Kesten S et al. Frequency of exacerbations adversely impacts the course of COPD. Am J Respir Crit Care Med 2010;181:A1526.Soler-Cataluna JJ, Martinez-Garcia MÁ, Román Sánchez P, et al. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax 2005;60:Groenewegen KH, Schols AMWJ, Wouters EFM. Mortality and mortality-related factors after hospitalization for acute exacerbation of COPD. Chest 2003;124:Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPDFaster disease progressionIncreased likelihood of hospitalisationAdapted from Wedzicha JA et al, 2007; Donaldson GC et al, 2006.
4 Reduce and Prevent exacerbation is easy We can predict high risk patientsWe can prevent exacerbationWe have guidelines
5 COPD Airway inflammation Airflow Obstruction Air Trapping Dyspnea on exertionInfection, pollutionMore ObstructionMore inflammationExacerbation
6 Association of disease severity and exacerbations Hurst JR(ECLIPSE), NEJM. 363; 1128::2010
8 Number of exacerbations per year stratified by baseline FEV1 ICS สามารถลดการกำเริบได้ISOLDE. BMJ2000;320:
9 Rate of moderate and severe exacerbations over three years Mean number of exacerbations/year25% reduction18.104.22.168*10.93*0.85*†‡0.80.60.4Moderate exacerbations are defined as those which require treatment with systemic corticosteroids and/or antibiotics; severe exacerbations are defined as those which require hospitalisation. The exacerbation rate was calculated as the total number of moderate and/or severe exacerbations experienced by a patient during the treatment period.The number of exacerbations was analysed using a generalised linear model, assuming the Negative Binomial distribution, with time on treatment as an offset variable. The model included adjustments for the effects of smoking status, age, gender, baseline FEV1, number of exacerbations reported in the 12 months prior to screening, and region.1SFC significantly lowered the rate of moderate/severe exacerbations compared with placebo (25% reduction, p < 0.001), SALM (12% reduction, p = 0.002) and FP (9% reduction, p = 0.024). SALM and FP also had significantly lower exacerbation rates than placebo (15%, p < and 18%, p < 0.001, respectively).1SFC reduced the rate of moderate-to-severe exacerbations to a much greater extent than placebo or either of the component monotherapies.1Exacerbations and hospitalisations predict the risk of dying from COPD over 5 years.2ReferenceCalverley PMA, Anderson JA, Celli B. for the TORCH investigators. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. NEJM 2007; 356(8): & Online SupplementSoler-Cataluna JJ, Martinez-Garcia MA, Roman Sanchez P, et al. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax 2005;60:925–31.0.2PlaceboSALMFPSFCTreatmentCalverley et al. NEJM 2007*p < vs placebo; †p = vs SALM; ‡p = vs FP
10 Exacerbation rate by baseline post-bronchodilator FEV1 % predicted Jenkins. Respir Res 2009: 59
11 SFC: impact of exacerbation history (TORCH)1 In patients with a history of more frequent exacerbations, there were trends to higher rates overall, and a greater effect of treatmentReductions in exacerbation rates associated with treatment are not dependent on a history of frequent exacerbations, and the benefits of SFC on exacerbations are still seen in patients who had no history of an exacerbation in the previous 12 monthsExacerbation history: impact of SFC% reductionNo recalled exacerbations191 exacerbation in previous year26≥2 exacerbations in previous year31NotesA sub-group analysis of TORCH data showed trends to higher rates of exacerbation, and a greater effect of treatment, in patients with a history of more frequent exacerbations. [par5/ln1–2]However, there was no significant interaction between exacerbation history and effect of treatment (p=0.34). [par5/ln2–3]Adjusted mean exacerbation rates among SFC patients were 0.64 in those with no exacerbations in the previous year, 0.89 in those with one exacerbation and 1.21 in those with two or more exacerbations; percentage reductions versus placebo were 19%, 26% and 31%, respectively. [Table]ReferenceJenkins C et al. Poster 227, ERS 2007.1. Jenkins C et al. Poster (227) presented at ERS 2007.
12 Pharmacotherapy: Glucocorticosteroids Management of Stable COPDPharmacotherapy: GlucocorticosteroidsThe addition of regular treatment with inhaledglucocorticosteroids to bronchodilator treatment is appropriate for symptomatic COPD patients with an FEV1 < 50% predicted (Stage III: Severe COPD and Stage IV: Very Severe COPD) and repeated exacerbations (Evidence A).
16 Identification of patient at risks ไม่ทำอะไร เป็นน้อยอยู่ Arterial stenosisAirway obstructionIdentification of patient at risksไม่ทำอะไร เป็นน้อยอยู่Heart attackCOPDexacerbationCatheterization and revascularzation?????????AntiplateleteAnticoagulationACEI
18 C D A B GOLD 2011 revision GOLD 4 >2 GOLD 3 2 Future risks Exacerbations / y1GOLD 2ABGOLD 1MRC 0-1CAT<10MRC 2+CAT 10+Current symptoms
19 C D A B GOLD 2011 revision SABA or SAMA LABA or LAMA ICS/LABA ICS/LABA >2ICS/LABAorLAMACDGOLD 32Future risksExacerbations / y1GOLD 2SABAorSAMALABAorLAMAABGOLD 1MRC 0-1CAT<10MRC 2+CAT 10+Current symptoms