TITLE Respiratory Training Session Deepa Tailor Medicines Management

TITLE Respiratory Training Session Deepa Tailor Medicines Management Pharmacist NHS Nottingham City Clinical Commissioning Group DATE: Tuesday 12 th June 2018 Working together for a healthier Nottingham

Content • • • What is COPD? GOLD 2017 NICE APC COPD Guideline Which 2 Drugs for dual therapy? Inhalers on COPD formulary What is Asthma? BTS/SIGN, NICE Guidelines APC Asthma guideline in adults Inhalers on Asthma formulary Working together for a healthier Nottingham

What is COPD? NICE Chronic obstructive pulmonary disease (COPD) is a condition characterised by airflow obstruction, which is usually progressive, not fully reversible and does not change markedly over several months GOLD “a common, preventable a treatable disease that is characterised by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases” Working together for a healthier Nottingham

GOLD 2017 – How to categorise risk Spirometrically confirmed diagnoses Post-bronchodilator FEV 1/FVC <0. 7 Assessment of symptoms/risk of exacerbation Assessment of airflow limitation Percentage predicted FEV 1 GOLD 2 ≥ 80% 50 -70% GOLD 3 GOLD 4 30 -49% <30% Working together for a healthier Nottingham GOLD A Gold C <2 exacerbations or 0 admissions in the last year AND (MRC score 0 -1 or CAT score <10) GOLD B <2 exacerbations or 0 admissions in last year AND (MRC score >2 or CAT score ≥ 10) ≥ 2 exacerbations or ≥ 1 admission in last year AND (MRC score 0 -1 or CAT score <10) GOLD D ≥ 2 exacerbations or ≥ 1 admission in last year AND More symptoms (MRC score ≥ 2 or CAT score ≥ 10)

MRC Dyspnoea Scale Working together for a healthier Nottingham

COPD Assessment Tool (CAT) Working together for a healthier Nottingham

GOLD 2017 – Suggested treatments • category A: bronchodilator (short or long acting); consider switching to another depending on response; • category B: long-acting bronchodilator (LAMA or LABA), or both LAMA and LABA if symptoms not controlled on one drug; • category C: LAMA; consider switching to LAMA+LABA or to LABA+ICS if further exacerbations occur (LAMA+LABA now preferred over LABA+ICS); • category D: LAMA+LABA initially (unless high blood eosinophil counts or people with asthma-COPD overlap syndrome (ACOS), in which case LABA+ICS may be preferred); consider triple therapy if symptoms persist. Working together for a healthier Nottingham

NICE • Post-bronchodilator spirometry should be used to make diagnosis. • Pulmonary Rehab is an important component of care. • Trial therapy and if no objective/subjective improvement – Don’t be afraid to stop it. Working together for a healthier Nottingham

NICE SABA or SAMA prn Start LAMA continue SABA (if using) stop SAMA (if using) Add LABA Consider SABA or SAMA AND if FEV 1 <50% add LABA with ICS in combined inhaler If addition of LABA insufficient, add ICS, even if FEV 1 ≥ 50% (use combined inhaler) Regardless of severity, consider LABA & LAMA if ICS not tolerated/wanted. TRIAL OF TRIPLE THERAPY ICS + LABA + LAMA Absolute benefits small: reduction of 1 exacerbation over 8 years (Lancet 2016; 388: 963). Working together for a healthier Nottingham

NNT = 2 to improve exercise tolerance, 4 to reduce readmission 6/12 NNT = 5 prevent death at age 70 Working together for a healthier Nottingham

APC COPD GUIDELINE Non-Pharmacological Treatments • Stop smoking • Pulmonary Rehab Pharmacological Treatments • Influenza Vaccination • Inhalers • Oxygen – O 2 Sats ≤ 92% - more than once when stable on optimal medication or 8 weeks after exacerbation • Oral steroids - A significant steroid load is >1 g over a year. NICE recommend 30 mg/d for 7 -14 d. So 1 g is 33 d at 30 mg/d. • The risk of fracture (typically vertebral) rises immediately oral steroid are started and returns to normal about 12 m after stopping. The extent depends on the dose used and duration of treatment (DTB 2010; 48(9)). Working together for a healthier Nottingham

APC COPD Guidelines Working together for a healthier Nottingham

Which 2 drugs for dual therapy? • A 12 m study of people with COPD who had an exacerbation in the previous 12 months compared LABA+LAMA (indacterol + glycopyrronium) with LABA+ICS (Salmeterol + fluticasone) (NEJM 2016; 374: 2222). The results showed: • The two arms were non-inferior. • In a modified intention to treat analysis there were fewer exacerbations in the LABA+LAMA arm, but the DTB review of the trial reminds us: • 75% of exacerbations were mild (25% required treatment) • There was no reduction in hospital admissions (DTB 2016; 58(8): 88). Working together for a healthier Nottingham

Working together for a healthier Nottingham

APC COPD Guidelines Working together for a healthier Nottingham

Inhalers • Several types of devices of which the below are on COPD guideline • p. MDI – Salbutamol, ipratropium, Fostair 100/6 , Symbicort 200/6 • Respimat – Olodaterol, Tiotropium, Spiolto • Easyhaler – Salbutamol and formeterol • Handihaler – Tiotropium (Recently changed to Zonda Inhaler (Braltus®)) • Turbohaler – Terbutaline, Formoterol, Symbicort • Genuair – Aclidinium (Eklira®), Duaklir® (aclinidinium/formeterol) • Ellipta – Umeclinidium (Incruse®), Anoro®(umeclidinium/vilanterol), Relvar® (fluticasone fuorate/vilanterol) • NEXThaler – Fostair® (beclometasone extrafine/formoterol) • Spiromax – Duoresp® (budesonide/formeterol) Working together for a healthier Nottingham

Inhalers Forceful, steady and deep inhalation action Working together for a healthier Nottingham Gentle prolonged and deep inhalation action

Useful Links • APC COPD Guidelines http: //www. nottsapc. nhs. uk/media/1063/copdguideline. pdf • APC Asthma Guidelines http: //www. nottsapc. nhs. uk/media/1049/adult-asthmaguideline. pdf? UNLID=5949407842018511154545 • Inhaler technique http: //www. nottinghamcity. nhs. uk/news-projects/inhaler -technique. html • In-check training http: //www. nottinghamcity. nhs. uk/portal-for-generalpractice/practice-resources/inhaler-technique. html Working together for a healthier Nottingham

What is Asthma? WHO: Can affect anyone in any age group. Characterized by recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from person to person. This condition is due to inflammation of the air passages in the lungs and affects the sensitivity of the nerve endings in the airways so they become easily irritated. In an attack, the lining of the passages swell causing the airways to narrow and reducing the flow of air in and out of the lungs. Working together for a healthier Nottingham

Diagnosis • No gold standard diagnostic testing – Influence probability, but do not prove diagnosis • Spirometry can be performed on anyone ≥ 5 years • Peak flow diary – Twice daily OR Four times daily if occupational asthma suspected • Fe. NO testing TAKE A GOOD HISTORY Working together for a healthier Nottingham

Asthma Review • Smoking • Inhaler Technique • Maintenance therapy • Pharmacotherapy • Lifestyle • Education Working together for a healthier Nottingham

Working together for a healthier Nottingham

BTS Guidelines – Management Working together for a healthier Nottingham

Working together for a healthier Nottingham

Single Inhaler Therapy for Maintenance and Relief (SIT) Working together for a healthier Nottingham

Any Questions Working together for a healthier Nottingham