Chronic Obstructive Lung Disease: GOLD Guidelines

Baylor College of Medicine Combined Med-Peds Program Anoop Agrawal, M.D.

COPD - Definition
Global Obstructive Lung Disease Guidelines
(GOLD) : first published in 2001

Disease state characterized by airflow

limitation that is no longer fully reversible and is usually progressive... This results in a chronic inflammatory response in the walls and lumen of the airways.

GOLD guidelines were recently updated in

2006

COPD - Prevalence
Affects 15 million Americans
Fourth leading cause of mortality (100,000/year) Only major health problem for which mortality
has been increasing for past 20 years

Results in 500,000 hospitalizations/year Second leading cause of missed work days There are numerous published guidelines GOLD being the most prominent (www.goldcopd.com)

 Hereditary - Alpha-1 Antitrypsin Deficiency Environmental Cigarette Smoking What percent of smokers will develop
COPD?

COPD - Risk Factors

15-20% (~1 in 5) - this implies a

genetic predisposition to developing COPD; tends to cluster in families

Occupational exposures to dust,

chemicals

COPD Diagnosis Symptoms

chronic cough - intermittent, nonproductive cough with sputum production, smokers cough dyspnea on exertion, usually progressive and
indolent

Spirometry

Should spirometry screening be performed on the

general population?

No, but in those with higher risk - i.e. all current

and former smokers over the age of 40 years with

The Importance of Screening for COPD

The Rule of 50s
50% of COPD patients are undiagnosed
(or approximately 12 million patients in U.S.)

COPD is evident by age 50

At time of diagnosis, FEV1 is <50%

predicted

50% 5-year survival rate

Raising COPD Awareness

November is National COPD Awareness Month World COPD Day took place on November 19th, 2008.

COPD Staging
Based upon the GOLD Guidelines - 2006
update

Classified into 4 stages

Staging is based primarily upon FEV1:

FEV1 < 80%

FEV1:FVC < 70%

The lower the FEV1 the more severe the

disease classification.

GOLD Guidelines for Therapy

COPD Management and Therapies

Vaccination - pneumococcal and influenza Regular Assessment of lung function - annually Cessation of tobacco use Drug Therapy:

short acting vs. long acting bronchodilators inhaled vs. oral corticosteroids

COPD - Management of Stable Disease

Smoking cessation: rate of FEV1 deterioration will
slow to near normal (20 ml /yr vs. 65 ml /yr for active smokers) if patient stops smoking

COPD - Drug Therapy

Therapy recommendations based on their
effect on FEV1.

First Line therapy: Beta agonists - short and long acting Anticholinergics - short and long acting Second Line therapy: Steroids - inhaled vs. oral Supplemental therapies

Beta agonists Mechanism of Action bronchodilate by stimulating Beta-2 receptors

Drug Albuterol Salmeterol

Studies show that COPD

patients do not develop tolerance to short acting or long acting beta agonists
Onset 1 to 3 min 20 min

Duration B2:B1 selectivity

4 to 6 hrs

12+ hrs

Asthmatics tend to
develop tolerance to short acting agonists

1375:1

85,000:1

Can Salmeterol be used

YES, salmeterol monotherapy had adverse outcomes in asthma study, note

Anticholinergics
Mechanism of actionbronchodilation by decreasing airway smooth muscle tone
Drug Ipratropium Tiotropium

Also reduces sputum

production

Onset

20 min

Combination of an
anticholinergic + B2agonist produces greater and more sustained rise in FEV1 than either drug alone.

Duration

4 to 8 hrs

24+ hrs

M1 and M3> Selectivity All Muscarinic M2

Tiotropium (Spiriva)
Studies show that once
daily tiotropium has resulted in a lasting increase in FEV1 out to one year.

174 ml above baseline

in good short-term responders

56 ml increase in poor
short-term responders
Tashkin,D. Chest 2003 May; 123:1441-9

Special delivery device.

Inhaled Corticosteroids (ICS)

Have not been shown to slow the progression of
disease or provide long term benefit

ISOLDE trial - patients with FEV1 of 50% predicted

value had a 25% reduction of exacerbations

Combination with salmeterol more effective in

reducing exacerbations than either drug alone

Unfortunately, recently published trial failed to

demonstrate statistically significant reduction in mortality with salmeterol/fluticasone combo.

Use of ICS increases likelihood of pneumonia.

New COPD Treatment Data

INSPIRE - study published in Jan 2008

compared salmeterol/fluticasone head to

head with tiotropium

No difference in exacerbation rate

although more in tiotropium group had higher drop out rate.

More patients in salmeterol/fluticasone

developed pneumonia.

Oral Corticosteroids
They have no proven benefit in stable COPD
Oral steroids are useful for acute
exacerbations

What is the recommended duration of

therapy?

Maximum benefit obtained during first 2

weeks of therapy.

Supplemental Therapies
Supplemental oxygen for hypoxemia (worn for
more than 15 hrs/day) has been shown to reduce moratality

What are the qualification parameters for

oxygen therapy?

PaO2 of 55mmHg or less, or pulse

oximetry of 88% or less

Pulmonary Rehabilitation

Lung reduction and lung transplantation

surgeries

GOLD Guidelines for Therapy

Summary
Early diagnosis, disease prevention,
smoking cessation and vaccination are important.

Initiate bronchodilator therapy early in

disease course, combination of albuterol with ipratropium most effective

Inhaled corticosteroids may be useful in

patients with severe disease or with objective responses on spirometry.

Will likely see inflammatory modulators

(TNF- in the future