Transcript Need for evidence-based guidelines

First World Conference
of COPD patients
http//pneumologia.unimo.it
Impact of co-morbid
conditions on care of
COPD patients
Leonardo M. Fabbri
[email protected]
a global mandate for COPD
care
Holiday Inn
Hotel
Rome 14 June
2009
Pathogenesis of COPD
Cigarette smoke
or air pollutant
CD8+ T-cell
?
Alveolar
macrophage
CXCR3
Inflammatory cytokines
(IL-8, LTB4)
Neutrophil
CXCL-10
Alveolar wall destruction
EMPHYSEMA
Proteases
Mucus hypersecretion
CHRONIC BRONCHITIS
Modified from Barnes, 2003
Leading Causes of
Death in U.S.
1. Myocardial
Infarction
2. Cancer
3. Cerebrovascular
Diseases
4. COPD
Cigarette Related Diseases
Leading Causes of
Death Worldwide 2010
Inhaled particles:
pulmonary and heart co-morbidity
Complex Chronic Comorbidities of COPD
Fabbri et al Eur Respir J 2008;31:204-212
Prevalence of heart failure in stable
‘COPD’ (aged 65 years or over)
Rutten FH et al, Eur Heart J 2005;26:1887-94
405 ‘COPD‘
 65years
244 (60.2%)
191 (39.8%)
COPD (GOLD)
‘rest’
48%
HF only
HF+COPD
COPD only
HF - / COPD -
12%
50 (20.5%)
33 (20.5%)
heart failure
Heart failure
8%
32%
Rutten FH et al, Eur Heart J 2005;26:1887-94
Prevalence of COPD and COPD severity in
patients with Chronic Heart Failure
% of patients
100
29 %
71 %
80
60
40
20
0
CHF + COPD
CHF
GOLD I
GOLD II
GOLD III
GOLD: Global Obstructive Lung disease
All but two of the patients were unaware of COPD
Boschetto, Ceconi, Ferrari et al Eur Heart J, in preparation
Therapy at Each Stage of COPD
I: Mild
II: Moderate
III: Severe
IV: Very Severe
 FEV1/FVC < 70%
 FEV1/FVC < 70%
 FEV1 > 80%
 FEV1/FVC < 70%
 FEV1/FVC < 70%
 50% < FEV1 < 80%
 30% < FEV1 < 50%
predicted
predicted
 FEV1 < 30% predicted
or FEV1 < 50% predicted
plus chronic respiratory
failure
predicted
Active reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator (when needed)
Add regular treatment with one or more long-acting bronchodilators
(when needed); Add rehabilitation
Add inhaled glucocorticosteroids if
repeated exacerbations
Add long term oxygen
if chronic respiratory
failure. Consider
surgical treatments
5-yrs mortality
The present study analysed data from 20,296 subjects aged >45 yrs at baseline in
the Atherosclerosis Risk in Communities Study (ARIC) and the Cardiovascular
Health Study (CHS).
Therapy at Each Stage of COPD
I: Mild
II: Moderate
III: Severe
IV: Very Severe
 FEV1/FVC < 70%
 FEV1/FVC < 70%
 FEV1 > 80%
 FEV1/FVC < 70%
 FEV1/FVC < 70%
 50% < FEV1 < 80%
 30% < FEV1 < 50%
predicted
predicted
 FEV1 < 30% predicted
or FEV1 < 50% predicted
plus chronic respiratory
failure
predicted
Active reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator (when needed)
Add regular treatment with one or more long-acting bronchodilators
(when needed); Add rehabilitation
Add inhaled glucocorticosteroids if
repeated exacerbations
Add long term oxygen
if chronic respiratory
failure. Consider
surgical treatments
What systemic aspects of COPD can be
affected by therapy
• Weakness
• Weight loss
• Cardiac risk
• Arrythmias
• Coagulability
• Depression
• Osteoporosis
• Fluid retention
Quality of Australian clinical guidelines and
relevance to the care of older people with multiple
comorbid conditions
Professional societies and charities should
be encouraged and supported to develop
clinical guidelines in compliance with
NHMRC requirements
Future guidelines should place more
emphasis on the management of older
people with multiple comorbid conditions
Vitri AL et al., MJA 2008; 189: 360–365
GUIDELINES FOR THE MANAGEMENT
OF CHRONIC KIDNEY DISEASE
Levin A. et al, CMAJ 2008; 179 (11):1154-1162
GUIDELINES FOR THE MANAGEMENT
OF CHRONIC KIDNEY DISEASE
BOX 1: Guidelines for the treatment of hypertension in patients
with chronic kidney disease
BOX 2: Guidelines for the treatment of diabetes in patients with
chronic kidney disease
BOX 3: Guidelines for the treatment of dyslipidemia in patients
with chronic kidney disease
BOX 4: Guidelines for lifestyle management for patients with
chronic kidney disease
• BOX 5: Guidelines for the measurement and treatment of
proteinuria in patients with chronic kidney disease
Levin A. et al, CMAJ 2008; 179 (11):1154-1162
GUIDELINES FOR THE MANAGEMENT
OF CHRONIC KIDNEY DISEASE
BOX 6: Guidelines for the treatment of anemia in patients with
stage 3-5 chronic kidney disease
BOX 7: Guidelines for the assessment and treatment of mineral
metabolism abnormalities in patients with chronic kidney
disease
BOX 8: Guidelines for preparation for initiation of renal
replacement therapy for patients with chronic kidney disease
BOX 9: Guidelines for comprehensive conservative management
for patients with chronic kidney disease
Levin A. et al, CMAJ 2008; 179 (11):1154-1162
Chronic Systemic Inflammatory Syndrome
(CSIS)
Age > 50 years
Smoking > 10 pack/years
Abnormal lung function
Ventricular dysfunction and/or ↑ BNP
Metabolic syndrome
↑ CRP
Fabbri and Rabe, The Lancet 1 September 2007
LYMPHANGIOLEIOMYOMATOSIS
I'm a 41 years old italian "Lammie", diagnosed with Lam in 2007, a rare and chronic desease
which destroys the lungs progressively. Many young women die prematurely because of
it. Unfortunately about Lam much is still unknown. Since my diagnosis I'm trying to do all I
can to talk to as much as possible to people, researchers, doctors about it and stimulate
their interest and to find more people in the world which can dedicate their studies to the
research of a cure and to get to know Lam.
The scientific community believes that the number of lam patients could be more than 30%
compared to the known cases as Lam is often confused with Emphysema or COPD or not
diagnosed at all . I thought that the Rome meeting could be a chance for us patients to
spread also the knowledge about Lam globally and an occasion promote the Lam sight,
which is which aims to create a global lam patient data.
I'm sending the copy of this message also to Doctor Amy Farber, who has made so much
for the global Lam community during the last years, founding the Lam Treatment Alliance in
Harvard.
www.lamtreatmentalliance.org, www.thelamfoundation.org
www.lamsight.org
LYMPHANGIOLEIOMIOMATOSIS
• Rare (1 per million) and progressive interstitial lung
disease of unknown etiology, which can occur sporadically
or in association with tuberous sclerosis.
• LAM almost exclusively affects females, generally
developing before menopause.
• There are a few case reports describing LAM in males and
children with tuberous sclerosis.
Dipartimento di Oncologia Ematologia e Pneumologia
Sezione di Malattie dell’Apparato Respiratorio
Direttore: Prof. Luca Richeldi
Dott. Fabrizio Luppi
Dott. Pietro Roversi
Dott. Paolo Spagnolo
Dott.ssa Giulia Cervi
Dott. Giacomo Sgalla
Dott.ssa Silvia Marani
First World Conference
of COPD patients
http//pneumologia.unimo.it
Impact of co-morbid
conditions on care of
COPD patients
Leonardo M. Fabbri
[email protected]
a global mandate for COPD
care
Holiday Inn
Hotel
Rome 14 June
2009