Departamento de Farmacología Clínica y Terapéutica. Campus Biomédico. Universidad de La Sabana.

1. GOLD16 – MANAGEMENT
AND TREATMENT OF COPD
Raphael Northoff-PTA (pharmaceutical & technical assistant)
Intern with Clinica Universidad de La Sabana

2. About GOLD
lounched in
1997
Health care
professionals
from over 50
different nations
Initial virsion of
guidelines in
2001
In collaboration
with NIH and
WHO
Updates
prepaered every
year
World COPD
Day
Relationships
with profit-
making
organizations

3. GOLD objectives
 Recommend effective COPD management and prevention strategies for use in all
countries.
 Increase awareness of the medical community, public health officials and the general
public that COPD is a public health problem.
 Decrease morbidity and mortality from COPD through implementation and
evaluation of effective programs for diagnosis and management.
 Promote study into reasons for increasing prevalence of COPD including relationship
with environment.
 Implement effective programs to prevent COPD.

4. The GOLD definition of COPD
 Chronic Obstructive Pulmonary Disease (COPD), a common preventable and
treatable disease, is characterized by persistent airflow limitation that is
usually progressive and associated with an enhanced chronic inflammatory
response in the airways and the lung to noxious particles or gases.
Exacerbations and comorbidities contribute to the overall severity in
individual patients.

5.  is a leading cause of morbidity and mortality worldwide and results in an
economic and social burden that is both substantial and increasing
 Inhaled cigarette smoke and other noxious particles such as smoke from
biomass fuels cause lung inflammation, a normal response that appears to be
modified in patients who develop COPD
  may induce parenchymal tissue destruction (resulting in emphysema), and
disrupt normal repair and defense mechanisms (resulting in small airway
fibrosis). These pathological changes lead to air trapping and progressive
airflow limitation and in turn to breathlessness and other characteristic symptoms
of COPD
COPD

6. FACTORS THAT INFLUENCE DISEASE
DEVELOPMENT AND PROGRESSION
COPD
GENS
AGE &
GENDER
LUNG GROWTH
AND
DEVELOPMENT
SOCIOECO-
NOMIC
SATTUS
EXPOSURE
TO
PARTICLES
ASTHMA,
BRONCHIAL
HYPERACTIVIT
Y
CHRONIC
BRONCHITIS
alpha-1 antitrypsin
Men ≈ women
Duration of exposure?
Gestation, birth,
childhood
“Childhood infections”
“Childhood
disadvantages'”
Poverty inversely related to risk
of developing COPD
Smoke, organic/ inorganic
dusts, chemical agents and
fumes, (indoor) air pollution,
occupational exp.
May be risk factor,
clinically separating
may not be easy
hypersecretion of
mucus decline FEV1,
young + smoking +
chronical bronchitis ↑
developing COPD

9. Pathophysiology
Airflow limitation and air
trapping – Gas
Exchange Abnormalities
Mucus Hypersecretion

10. Pathophysiology
Pulmonary
hypertension
Exacerbations

11. Inflammatory aspect asthma - COPD
 Both are associated with chronic inflammation of respiratory tract
BUT
 Differences in the involved inflammatory cells and mediators
for instance
COPD asthma
CD8+ (cytotoxic) Tc1 lymphocytes eosinophils, leukotriens, IL5
present only in smokers, neutrophilic
 Differences in pathological pathway, symptoms and response to therapy
 Some patients with COPD have features consistent with asthma and may have a
mixed inflammatory pattern with increased eosinophils

12. Pathophysiology - Comorbidities
COPD often coexists with other diseases that may havea significant impact prognosis!
Cardiovascular disease Depression Osteoporosis
Lung cancer Metabolic Syndrome & Diabetes GERD

13. Process of managing COPD
Diagnose
& Assess
Adjust
treatment
Review
response
Diagnose
Identify & reduce exposure to risk
factors
Inhaler technique & adherence
COPD medications
Non-pharmacologic treatment
Symptoms
Exacerbations
Side effects
Patient satisfaction
Lung function
Hospitalization
discharge and
follow up
ICU
Palliative
care

14. Diagnosis and Assessment
 Consider clinical diagnosis of COPD if patient has:
 dyspnea, chronic cough or sputum production, and a history of exposure to risk factors for
the disease
 Spirometry is required to make the diagnosis in this clinical context
 presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent
airflow limitation and thus of COPD
 Comorbidities occur frequently in COPD patients
 cardiovascular disease, skeletal muscle dysfunction, metabolic syndrome, osteoporosis,
depression and lung cancer
 can occur in patients with mild, moderate and severe airflow limitation and influence the
prognosis
 comorbidities should be actively looked for and treated appropriately if present
 Goals of COPD assessment:
 determine the severity of the disease (including severity of airflow limitation), the impact on
the patient’s health status, and the risk of future events (exacerbations, hospital admissions
and death)  guide therapy

15. Differential Diagnosis

16. Assessment of COPD
Symptoms
• CAT¹
• CCQ²
• mMRC³ (only
assessment of
breathlessness)
Airflow
limitation
• Based on post-
bronchodilator
FEV1 (GOLD
Classification 1-
4)
Risk of
Exacerbation
• Frequency and
hospitalization
Comorbiditis
• May influaence
mortlity and
hospitalization
• Look for routinely
and treat
appropiatly
¹ CAT COPD Assessment Test
² CCQ Clinical COPD Questionaire
³ mMRC modified British Medical Research Council

17. COMBINED ASSESSMENT OF COPD

18. Therapeutic options
 Smoking cessation!
 Greatest capacity to influence COPD !
 if effective resources and time are dedicated to
smoking cessation, 25% long term quit rates can
be achieved
PREVENTION COUNCELING
NICOTINE
REPLEACEMENT
THERAPY
Programs with clear,
consistent and repeated
nonsmoking messages
Smoke-free schools..
Even short counseling
results quit rates of
5-10%
Nicotine gum, inhaler or
spray, transdermal patch,
sublingual tablet etc.
Varenicline ?
Bupropion ?
Nortriptiyline ?

19. Therapeutic options
Occupational Exposure
Elimination or reduction of exposures in the workplace
Surveillance and early detection
Indoor and Outdoor Air Pollution
Reduce or avoid burning biomass for cooking and heating in
poorly ventilated dwellings
Advice patient to monitor public anouncements of air quality
Physical Activity
Remain activ!
All COPD patients benefit from regular physical activity

20. Pulmonary rehabilitation
Pulmonary
rehabilitation
Smoking
cessation
Exercise
training
Nutrition
counseling
education
Minimum 6 weeks
Continue at home!
Reduce anxious and
depression
Improves health related
quality of life as far as
survival
Those programs can be
costly
Encourage patient exercise
on his own !

21. Pharmacological therapies for stable
COPD
Improve health status and
exercise tolerance
Reduce symptoms/
frequency and severity of
exacerbations/ mortality
To date, none of the existing medications for COPD has been
conclusively shown to modify the long-term decline in lung function
when this is tested as a primary or secondary outcome in clinical trials

22. Care of the health!
 It is crucial for patients with COPD to understand the nature of their disease!
 education!
 Explain the COPD risk factors for its progression and their role in achieving optimal
health outcomes
 Ongoing monitoring including continuous evaluation of exposure to risk factors and
monitoring of disease progression
 general advice on healthy living, including diet and the fact that physical exercise is safe
and encouraged

23. evidence for the effectiveness of
pharmacologic treatments is not available
for patients with
FEV1 > 80% predicted
No evidence to recommend one
class of long-acting
bronchodilators over another for
initial treatment
Consider Combination of 2 long-
term bronchodilators if severe
breathlessness
Combination with PDE 4 inhibitor
may be considered if chronic
bronchitis
Unfortunately there is only one
study directly comparing ICS/ long-
acting beta agonist or long-acting
anticholinergic, which makes
differentiation difficult
First choice: inhaled corticosteroid
plus long-acting beta2-agonist or long-
acting anticholinergic, although there
are conflicting findings concerning this
treatment
second choice: combination of all
three classes of drugs (inhaled
corticosteroids/long-acting beta2-
agonist/long-acting anticholinergic)
“other possible treatments” if recommended first -
or alternative choice are unavailable or
unaffordable

24. Bronchodilators
are central to symptom management in COPD
 increase the FEV1 or change other spirometric variables
 usually widening of the airways (smooth muscles) rather than changes in lung
elastic recoil
 improve emptying of the lungs
 tend to reduce dynamic hyperinflation at rest and during exercise
 The extent of these changes, especially in severe and very severe patients, is not
easily predictable from the improvement in FEV1
 Dose – response : highly Increasing the dose of beta2-agonist/ anticholinergic
(especially nebulizers)  subjective benefit in acute episodes but not necessarily
helpful in stable disease

25. Bronchodilators
are central to symptom management in COPD
 Inhaled therapy is preferred
 The choice between different bronchodilators depends on availability and
individual response  symptoms relief and side effects?
 beta2-agonists
 Anticholinergics
 Theophylline
 Long acting bronchodilators
 convenient/ more effective at producing maintained symptom relief than short acting
bronchodilators
 Reduce exacerbations and related hospitalizations
 Combining may improve efficacy and decrease the risk of side effects compared to
increasing the dose of an single bronchodilator
Short acting Long acting
are prescribed on as-needed or on a regular basis

26. beta 2-agonists (SABA/ LABA)
 Selective stimulation of adrenergic receptors bronchial musculature
 Effect:
 Spasmolytic in bronchial tubes
 Bronchodilator effect
short  onset of action 1 - 5 min and relief for 3 - 6 hours
 Fenoterol, Salbutamol, Terbutaline ect.
long  slow onset and duration of 12 to 24 hours
 Formoterol (rapid onset), Salmoterol ect.

27. Anticholinergics
 inhibition of muscarinic Ach-receptors
 Bronchodilator effect by inhaling anticholinergic
 prevent wheezing, shortness of breath, coughing and chest tightness as b2-
agonist do
Tiotropium
Blocks selectively M1 and M3 for more than 24 hours
reduces exacerbations and related hospitalizations, improves symptoms
and health status and improves the effectiveness of pulmonary rehabilitation

28. Combination of Bronchodilators
 may increase the degree of bronchodilation or lesser side effects!
 long-acting beta2-agonist + long-acting anticholinergic
 significant increase in lung function whereas outcomes is still limited
 beta2-agonist + anticholinergic or theophylline
 may produce additional improvements in lung function and health status compared to
either medication alone
 Short-term formoterol and tiotropium has been shown to have a bigger impact on FEV1
than the single components
 short-acting beta2-agonist + anticholinergic
 greater and more sustained improvements in FEV1 than either drug alone
(does not produce evidence of tachyphylaxis over 90 days of treatment)

29. Methylxanthines
 Controversy remains of the exact effect f xanthine derivatives
 Unspecific adenosine-receptor agonist, antagonizing equally A1, A2, A3
 A2b (A3) responsible for release of inflammatory mediators
 Unspecific Inhibition of phosphodiesterase (PDE)
 in so doing also bronchodilatating effect
Theophylline
metabolized by cytochrome P450/ Clearance declines with age
many other physiological variables and drugs modify theophylline
All studies that have shown efficacy of theophylline in COPD were performed with slow-release
preparations
Theophylline is less effective and less well tolerated than inhaled long-acting bronchodilators

30. Corticosteroids
 Inhaled Corticosteroids (ICS)
 only as combination therapy
 dose-response relationships and long-term safety of ICS in COPD are not known
 their role in the management of stable COPD is limited to specific indications
 if FEV1 < 60% predicted regular treatment with ICS improves symptoms, lung function, and
quality of life, and reduces the frequency of exacerbations
 Only moderate to high doses have been used in long-term clinical trials
 Oral Corticosteroids (OCS)
 Long-term treatment is not recommended (numerous side-effects)
 for treating acute exacerbations  improve symptoms, lung function, reduce rate of treatment
failure, and shorten length of hospital stay
 preventing a subsequent exacerbation

31. Combination ICS/ Bronchodilator
 ICS + long-acting beta2-agonist
 more effective than the individual components in improving lung function and health
status and reducing exacerbations in moderate to very severe COPD
 addition of a long-acting beta2-agonist/ ICS combination to tiotropium
 improves lung function, quality of life and may reduce exacerbations (more studies of
triple therapy are needed
 is associated with an increased risk of pneumonia

32. Phosphodiesterase inhibitors
(PDE – inhibitors)
Oral administration once daily
 principal action is to reduce inflammation by inhibiting of the breakdown of
intracellular cyclic AMP
 no direct bronchodilator activity
 improve FEV1 in patients treated with salmeterol or tiotropium
 May be helpful for patients with chronic bronchitis
 should always be used in combination with at least one long-acting bronchodilator!
 Representing drug: Roflumilast

35. Mucolytics and Antioxidant Agents
 a few patients with viscous sputum may benefit from mucolytics, benefits seem to
be very small
 widespread use of these agents cannot be recommended at present
 In most common use:
 N-acteylcystein, also an antioxidative agent
 could maybe have a role in the treatment of patients with recurrent exacerbation
 Cystein

36. Other pharmacological treatments
Vaccines
• Influenza vaccination can reduce serious
illness(lower respiratory tract infections) requiring
hospitalization up to death in COPD patients
• Pneumococcal polysaccharide vaccine
recommended for COPD patients ≥ 65 years
younger patients with significant comorbid conditions
Alpha-1 Antitrypsin Augmentation
• only young patients with severe hereditary alpha-1
antitrypsin deficiency and established emphysema
may be candidates
• very expensive, is not available in most countries
Antibiotics
• Not recommended,
except for treatment of
infectious exacerbations/
other bacterial infections
Vasodilators
• nitric oxide is
contraindicated in stable
COPD
Antitussives
• Cough has a significant
protective role

37. Other treatments
Oxygen therapy
• increase survival in patients with severe
resting hypoxemia
• Indicated for PaO2 ≤ 8.0 kPa/ SaO2 ≤ 88%,
pulmonary hypertension, congestive
cardiac failure, polycythemia ?
Ventilatory support
• Non-invasive ventilation (NIV) is
increasingly used in patients with stable
very severe COPD
• contradictory results regarding the clinical
benefits of long-term NIV
NIV + long-term O2 may
be of some use in a
selected subset of
patients
It may improve survival
but does not improve
quality of life
patients with COPD and
obstructive sleep apnea
benefit from continuous
positive airway pressure
(CPAP) in survival and
risk of hospital
admission

38. Surgical treatments
 Lung Volume Reduction Surgery (LVRS)
 parts of the lung are resected
 reduce hyperinflation making respiratory muscles more effective pressure generators by
improving their mechanical efficiency In addition LVRS increases the elastic recoil pressure of
the lung and thus improves expiratory flow rates and reduces exacerbations
 advantage of surgery over medical therapy more significant among patients with
predominantly upper-lobe emphysema and low exercise capacity prior to treatment
 Lung Transplantation
 appropriately selected patients with very severe COPD improve quality of life and functional
capacity
 post-operative mortality, acute rejection, fungal or bacterial infections etc.
 limited by the shortage of donor organs and costs

39. Treatment of Exacerbations
 exacerbation of COPD
 acute event
 worsening of the patient’s respiratory symptoms beyond normal day-today variations
 change in medication
 most common precipitating factors
 viral upper respiratory tract infections
 infection of the tracheobronchial tree
 diagnosis of an exacerbation
 clinical presentation of the patient complaining of an acute change of symptoms (baseline dyspnea,
cough and/ or sputum production), beyond day-to-day variations
 goal of treatment in COPD exacerbation
 minimize the impact of the current exacerbation
 prevent the development of subsequent exacerbations

40. Exacerbation – severity assessment
 Arterial blood gases measurements
 Pa02 < 8.0 kPa with or without PaCO2 > 6.7 kPa  respiratory failure
 Chest radiographs to exclude alternative diagnoses
 ECG – coexisting of cardiac problems ?
 Other laboratory tests
 Whole blood count  polycythemia or bleeding ?
 Purulent sputum  empirical antibiotic treatment ?
 Biochemical tests  electrolyte disturbances, diabetes, poor nutrition ?

41. Exacerbation - Treatment options
Oxygen
 key component of hospital treatment of an exacerbation.
 titrated to a target saturation of 88-92%
Bronchodilators
 short-acting inhaled beta2-agonists with or without short-acting anticholinergics
 Intravenous methylxanthines (theophylline/ aminophylline) may be considered as
second-line therapy if insufficient response to short-acting bronchodilators
Systemic corticosteroids
 shorten recovery time, improve lung function, arterial hypoxemia reduce the risk of early
relapse, treatment failure, and length of hospital stay

42. Exacerbation - Treatment options
Antibiotics
infectious agents in COPD exacerbations can be viral or bacterial
 use remains controversial
Antibiotics should be given to patients:
 with increased dyspnea, increased sputum purulence (+ sputum volume)
 Who require mechanical ventilation
antibiotics for only moderately or severely ill patients with COPD exacerbations with
increased cough and sputum purulence