Transcript Prescribing for patients with COPD Evidence Update

Prescribing for patients
with COPD
Evidence Update
Emma Blanden- Pharmacist
Inhaled drug treatment of COPDoutcomes
Reduce
symptoms
Improve quality of life
Reduce exacerbations
Reduce
deterioration in lung function
Reduce
mortality
Reducing symptoms

Most drugs improve symptoms

Assess & record response to treatment–MRC
score, ability to do activities of daily living,
exercise capacity

Review diagnosis

Inhaler technique

Trial of therapy- if it doesn’t work don’t be afraid
to stop it
Reducing exacerbations
LAMAs & LABAs
POET-COPD trial 2011
Tiotropum vs Salmeterol RCT 7376 patients
time to first exacerbation greater with tiotropium
187 days vs 145 days
•
•
•
patients continued treatment with ICS throughout study
(not NICE)
no info in patients with mild COPD
no info about comparisons with other LABAs
Tiotropium may be more effective than salmeterol in terms of
exacerbations but the evidence is currently unclear
Reducing exacerbations- ICS
Reducing exacerbations
The “frequent exacerbator’’
(more than 2 exacerbations/ year)


Best predictor of having another exacerbation is
frequency of past exacerbations
Effects on lung function

Limited evidence of clinically significant impact
for any drug

Tiotropium UPLIFT trial- clinically important
amount??

Significant person to person variation & no good
predictors of who most likely to deteriorate

Stopping smoking reduces decline
Reducing mortality

SAMAs – increased risk of mortality?

SABAs- no increased risk

LABAs- no evidence of impact

LAMAs- UPLIFT trial showed no impact (but nonsignificant trends towards reducing mortality)

ICS- Cochrane review- no impact
Tiotropium (Spiriva)
Respimat-safety
• significantly increased risk of mortality
• greatest risk seen in patients with more severe
COPD and at a higher daily dose.
• risk was more evident for cardiovascular death
• Excess risk not apparent with Handihaler
• Current MHRA Advice:
Use Respimat with caution in patients with known
cardiac rhythm disorders.
Remind patients on tiotropium not to exceed the
recommended doses
Inhaled corticosteroids- risks

1 extra case of pneumonia for every 47 people
treated with ICS over 1 year

1 person will develop diabetes for every 21
patients treated with ICS over 5 years

1 extra fracture for every 80 people treated with
ICS over 3 years
Drug treatment of COPD-outcomes
Reduce
symptoms
Improve quality of life
Reduce
Reduce
exacerbations
deterioration in
lung function
Reduce mortality
Good evidence
for all inhaled
drugs
Evidence for
some drugs
Limited evidence
Little evidence
Inhaled drug treatment –
what are we trying to achieve?
Improving symptoms
Most drugs improve symptoms
 Inhaler technique
 Record severity and symptoms & assess response to treatment
 Trial of inhaler therapy – if it doesn’t work stop it and try another
Reducing exacerbations
Tiotropium and LABAs reduce exacerbations
ICS reduce exacerbations – but side effects
Identify “frequent exacerbators’’ – most likely to benefit from treatment
Review ICS treatment for patients with mild- moderate disease without
exacerbations
 Before starting ICS consider potential benefits treatment and risks of
harm for individual patient


COPD ‘Value’ Pyramid
What we know…. Cost/QALY
Triple
Therapy
£35,000£187,000
LABA
£8,000/QALY
Tiotropium
£7,000/QALY
Pulmonary Rehabilitation
£2,000-8,000/QALY
Stop Smoking Support with
pharmacotherapy £2,000/QALY
Flu vaccination £?1,000/QALY in “at risk” population
Stage 2: Moderate
FEV1 ≥ 50%
LABA
Formoterol 12 microg
twice daily
Easyhaler £12
Atimos MDI £18
or
Salmeterol 50 microg
Accuhaler /MDI
twice daily £30
LAMA
Tiotropium
(Spiriva Handihaler®)
18 microg once daily £32
or
Glypyrronium
(Seebri Breezhaler®)
50 microg once daily £28
or
Aclidinium
(Eklira Genuair®)
400 microg twice daily £29
discontinue ipratropium
New LAMAs
Glypyrronium
(Seebri®)
once daily
Aclidinium
(Eklira Genuair®)
twice daily

similar efficacy to tiotropium

no robust evidence of any advantage over tiotropium or other longacting bronchodilators

no long term data on effectiveness or safety

APC advice: as an option for new patients, do not switch
Combined inhalers BDP equivalence
(note the dose of long acting
bronchodilator (LABA) may vary)
BDP
equivalence
Daily dose
Licensed
for use in
COPD
Cost for
30 days
Fostair® (BEC + formeterol) 100/6 MDI
2pBD (120dose)
Symbicort® (BUD + formeterol) 400/12
1pBD (60 dose)
Symbicort® (BUD + formeterol) 200/6
2pBD (120 dose)
Flutiform® ( FLU + formeterol) 250/10
MDI 1pBD (120 dose)
Seretide ® 250/50 ACCUHALER 1P BD
(60 dose)
Flutiform® ( FLU + formeterol) 250/10
MDI 2pBD (120 dose)
Seretide® 500/50 ACCUHALER 1p BD
(60 dose)
800-1000mcg no
£29.32
Expected
no
inhalers/
yr
13
800mcg
yes
£38.00
13
800mcg
yes
£38.00
13
1000mcg
no
£22.78
7
1000mg
no
£35.00
13
2000mg
no
£45.56
13
2000mg
yes
£40.92
13
Mucolytic therapy
Consider in people with a chronic productive cough and continue
use only if symptoms improve.

Mucolytics do not prevent exacerbations. Many patients end up
on long-term mucolytics after starting during an acute
exacerbation. Stop mucolytics routinely after an exacerbation and
reassess before re-starting.

Carbocisteine capsules or oral liquid: 750mg three times a day for 4
weeks (capsules 375mg: Liquid 250mg/5mls)
If no benefit after 4 weeks- stop treatment. If beneficial continue
with 750mg twice a day.
Treatment of COPD exacerbations

Increase frequency of bronchodilator use

Prednisolone 30mg once daily for 7-14 days

Antibiotics 5-7 days: See Worcestershire Guidelines for Primary
Care Antimcirobial Prescribing
1st line- amoxicillin 500mg tds or doxycycline 200mg stat then
100mg daily.
2nd line- clarithromycin 500mg bd
3rd line - co-amoxiclav 625 mg tds If resistance risk factors (co-morbid
disease, severe COPD, frequent exacerbations, antibiotics in last 3
months)

Standby home packs