COPD-Management NICE

Chronic obstructive pulmonary disease- a summary of NICE draft July 2018.

Smoking cessation- Take and document hx of smoking
○ pack yrs smoked 
ie No of cigs / D divided by 20 and multiplied by number of yrs smoked
 Advice to stop smoking at every opportunity – regardless of age and offer help to do so
 Consider issuing – unless contraindicated
○ nicotine replacement therapy
○ vareniciline or
○ bupropion
appropriate support Programme for Behavioral support

Inhaled therapy –Short acting beta2 agonists ( SABA ) and Short acting muscarinic antagonists ( SAMA ) as necessary as the initial treatment to relieve breathlessness and exercise limitation – as necessary . NICE advices against using a response to oral corticosteroid 
( oral corticosteroid reversibility tests ) to select patients for initiation of inhaled steroid therapy
 Be ready to discuss the risk of side effects 
( including pneumonia ) in people who take inhaled corticosteroids
( ICS ) for COPD )

Inhaled combination therapy- This refers to combinations of LAMA , LABA and ICS ie 
Long acting preparations as opposed to Short acting when initiating treatment
 LAMA is long acting muscarinic antagonists as
glycopyrronium , umeclidinium , aclidinium
 LABA is long acting beta2 agonists as
Indacaterol , formoterol , striverdi

The draft advices against assessing the effectiveness of bronchodilator therapy using lung function along. It recommends taking into account various other measures as improvement in symptoms , activities of daily living , exercise capacity and rapidity of symptoms relief

LAMA o+ LABA –spirometry confirms COPD and do not have asthmatic features / features suggesting steroid responsiveness and remain breathless or have exacerbations despite
○ Rx for tobacco dependence and if they smoke and
○ optimised non-pharmacological management and relevant vaccinations and
○ using short acting bronchodilator

LAMA + LABA + ICS-COPD with asthmatic features / features suggesting steroid
 responsiveness who remain breathless or have exacerbations despite taking LABA + ICS

Inhalers –Draft suggests that most people can develop adequate inhaler technique with training irrespective of age It acknowledges that people with sig cognitive impairment may not be able to use any form of inhaler device Hand held inhaler ( with a spacer if appropriate ) is the best mode in most cases to administer bronchodilator therapy Offer an alternative inhaler – if a person is unable to use a particular one correctly or it is not suitable for them Ensure that training has been provided and patient is able to demonstrate satisfactory technique Regularly assess and correct technique if necessary

Spacer –Check compatibility Advice about usage Hand wash not more than once a month with warm water and washing up liquid and allow the spacer to air dry

Nebulizer-Distressing and disabling breathlessness despite maximum therapy via inhalers Check if they/carers have the ability to use before prescribing Only continue nebulised therapy if confirmed 
○ reduction in symptoms
○ ↑↑ ed ability to undertake ADL’s
○ ↑↑ in exercise capacity
○ improvement in lung function Offer choice between facemask and mouthpiece when possible Ensure supply , maintenance and support of necessary equipments

Oral steroids –Oral corticosteroids are not recommended for long term use If unable to to withdraw -keep the dose as low as possible Monitor and provide osteoporosis prophylaxis
People over 65 start prophylaxis without monitoring

Short acting theophylline-Use only after trial of
○ short acting bronchodilators and long acting bronchodilators OR
○ If unable to use inhaled therapy Plasma levels and interactions need to be monitored Use with caution in elderly
○ differences in pharmacokinetics
○ increased likelihood of comorbidities and use of other medications Assess effectiveness Reduce the dose of theophylline if prescribed macrolide or fluoroquinolone antibiotics for exacerbations OR
other drugs known to interact 

Mucolytic- For people with chronic cough productive of sputum Only cont if symptoms improve Do not use routinely to prevent exacerbations in people with stable COPD

Oral azithromycin prophylactic –do not smoke and optimised 
○ non-pharmacological management
○ inhaled therapy
○ vaccinations if appropriate
○ have been referred for pulmonary rehabilitation and

Continue to have one or more of the following , particularly if they have sig daily sputum production

○ frequent ie 4 or more exacerbations / year with sputum production
○ prolonged exacerbations with sputum production
○ exacerbations resulting in hospitalisation .sputum culture – r/o resistant organisms and Pseudomonas aeruginosa ie r/o bronchiectasis training in airway clearance techniques to optimise eputum clearance CT scan to r/o bronchiectasis and other lung pathologies ECG ( r/o prolonged QT interval ) Baseline liver function tests. The draft / guidance doesn’t clearly specify who should initiate this and mentions ” Think about whether respiratory specialist input is needed ” but in clinical practice initiation of prophylactic antibiotic is usually a decision made by the chest clinic . We would suggest you should refer to secondary care for this.

Inform about small risk of hearing loss and tinnitus with azithromycin and seek help if this occurs If azithromycin contraindicated consider Doxycycline @ 100 mg/ D Review after 3 months and than atleast every 6 months Only cont Rx if benefits outweigh risks Draft states that no long term studies on the use of prophylactic antibiotics in people with COPD . 

A recent Cochrane Systemic Review of 14 RCTs involving 3932 participants between 2001-05 has found -
○ with use of antibiotics , the number of participants who developed an exacerbation reduced markedly
○ 3 / week may be more effective than daily use followed by a break of several weeks
○ may been a benefit on patient- reported quality of life
○ no affect on number of deaths due to any cause , frequency of hospitalization , loss of lung function during study period
○ risk of adverse affects and resistance
 The draft also touches on using antibiotic for exacerbations and states evidence of limited benefits and risk of antimicrobial resistance. A guidance on managing exacerbations is expected by Dec 2018. Currently patients who are still at risk of exacerbation despite taking azithromycin should keep a non macrolide antibiotic at home as part of the rescue pack

Referral-Diagnostic uncertainty ( also see chart on COPD diagnosis ) Suspected severe COPD Patient with COPD requests a 2nd opinion Cor pulmonale Assessment for oxygen therapy Assessment for long term nebulizer Rx Assessment for oral corticosteroid Rx Bullous lung disease Rapid decline in FEV1 Assessment for Pul rehab Assessment for lung volume reduction procedure Assessment for lung transplantation Dysfunctional breathing Onset before age 40 or a family h/o alpha1 anti-trypsin deficiency Symptoms disproportionate to lung function deficit Frequent infections Haemoptysis

Also for prophylactic antibiotic therapy

Vaccination-Pneumococcal and annual influenza vaccination to all people 
with COPD

 Restrict use of antibiotics for COPD NICE says BMJ 2018 ; 362;k3016 Herath SC, Normansell R, Maisey S, Poole P. Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD). Cochrane Database of Systematic Reviews 2018, Issue 10. Art. No.: CD009764. DOI: 10.1002/14651858.CD009764.pub3. National Institute for Health and Care Excellence Guideline Chronic Obstructive pulmonary disease in over 16s : diagnosis and management Draft for consultation , July 2018