Con la SPIROMETRIA 03/12/2015. La BPCO: come diagnosticarla, come trattarla. Mario Polverino

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1 La BPCO: come diagnosticarla, come trattarla Mario Polverino Polo Pneumologico Provinciale Centro Regionale Ad Alta Specializzazione PO «M. Scarlato», SCAFATI (SA) Scuole di Specializzazione in Pneumologia, Farmacologia Con la SPIROMETRIA

2 Broncodilatatori Antinfiammatori Con la SPIROMETRIA SPIROMETRIC DIAGNOSIS Fixed ratio or LLN? A Review of Available National Guidelines of Treatment of COPD in Europe. Miravitlles, Vogelmeier, Roche, Halpin, Cardoso, Chuchalin, Kankaanranta, Sandström, Śliwiński, Zatloukal, Blasi [in press]. Czech Republic: CZ. England: EN. Finland: FI. France: FR 5. Germany: GE 6. Italy: IT 7. Poland: POL 8. Portugal: POR 9. Russia: RU 0. Spain: SP. Sweden: SW

3 Diagnosis FEV/FVC < 70: EN, FR, GE, FI, PO, RU FEV/FVC < LLN: CZ, IT, POL, and SW maschi Mannino et al, Thorax 006 Femmine

4 La diagnosi spirometrica non è diagnosi precoce. E la diagnosi di malattia presente. Simplification of diagnostic criteria, particularly for primary care physicians, could significantly enhance patient identification and initiation of care L importante è che venga fatta Lancet Respir Med. 0 Nov;():869-7

5 Ass. %teor. FEV.78 FVC.5 8 IT FVC 8 5

6 Ass. %teor. FEV. 0 FVC IT FVC 87 Ass. %teor. FEV.6 80 FVC. 8 IT FVC 80 6

7 Ass. %teor. FEV FVC IT FVC 90.5 Ass. %teor. FEV FVC IT FVC 90.5 Nonostante la terapia (!) la paziente peggiora notevolmente, rapidamente, in pochi mesi e viene a consulto 7

8 Ass. %teor PRIMA UIP DOPO FEV FVC IT 7 All EO: VELCRO BIBASILARE PRIMA Ass. %teor. DOPO Ass. %teor. PRIMA Ass. %teor. DOPO Ass. %teor. FEV FEV FEV FEV FVC IT 90.5 FVC IT 7 FVC IT 90.5 FVC IT 7 8

9 Lancet Respir Med. 0 Nov;():

10 Phenotypes Broncodilatatori Antinfiammatori CB/E: CZ, EN, POL, RU, SP and SW Frequent exacerbator: CZ, EN, FI, POL, POR, RU, SP and SW EX: CZ and FR EX or SEVERE (hospitalization): FI, RU, POR and SP EX or SEVERE (hospitalization) + FEV <50%: POL ACOS: CZ, FI, RU, SP, FR and SW Miravitlles et al. Arch Bronconeumol 0; 8: 7-57 ACOS Overlap COPDasthma phenotype Exacerbator phenotype ( or more ex/yr) No exacerbations < ex/yr E (A) CB (B) NON è un asmatico che fuma!!! 0

11 Treatment Goals CZ, FI, FR, POL, POR and SW: reducing symptoms, averting the natural progression of the disease, improving QoL, enhancing PA, preventing complications and adverse consequences, and increasing life expectancy GE and SP: improvement of symptoms, exercise capacity, and QoL; and reduction of exacerbation frequency RU: short-term (symptom relief and improvement of exercise tolerance and QoL) and long-term (preventing disease progression and exacerbations and decreasing mortality IT: not explicitly stated: The main goal of pharmacotherapy is the bronchodilation. Treatment Selection ICS (+BD) In the majority of guidelines roughly similar. FEV <50% (or <60%) and/or with a history of EX ACOS. in patients not managed with BD alone Theophylline Recommended with reservations by all countries except Italy.

12 Roflumilast Macrolides Recommended in CB-phenotype and EX in most countries Alternative treatment for stable disease in patients still experiencing exacerbations despite optimal treatment (CZ, FI, RU and SP). NAC/carbocysteine Recommended in CZ, EN, POL, RU and SP Impact of Comorbidities on COPD Treatment

13 Impact of Comorbidities on COPD Treatment FI and RU: caution/ careful consideration in use of : ICS in patients with or at risk for osteoporosis, diabetes, and pneumonia high-dose β-agonists in patients with cardiovascular disease Trattamento farmacologico Uso CSI limitato stadi più avanzati o a pazienti con almeno R / anno ICS + LAMA ICS + LABA S o o LAMA ICS+LABA+LAMA ICS/LABA+ PDE T a opzione LAMA+LABA; GOLD 0 LAMA + LABA A LAMA + PDE Riacutizzazioni anno D I (A) SABA o SAMA a opzione LAMA o LABA o SABA + SAMA MRC 0 CAT < 0 LAMA o LABA a opzione LAMA + LABA MRC + CAT 0 + (B) < I broncodilatatori sono il trattamento cardine della BPCO e gli unici indicati negli stadi lievi/moderati ( < riacutiz/anno ) r i a c u t i z z a z i o n i/ a n n o FARMACOTERAPIA DELLA BPCO STABILE (7/0) < > SABA o SAMA (LAMA O LABA?)? LAMA o LABA LABA + LAMA LABA o LAMA (LABA+ ICS) 80% 60% 50% VEMS % del predetto LABA + ICS LAMA + LABA + ICS LAMA + LABA LABA o LAMA LAMA o LABA + roflumilast sintomi Persone con BPCO% 50% 0% 0%

14 LABA o LAMA LABA o LAMA LABA o LAMA + CSI o PDE LABA + CSI LABA + LAMA + CSI o PDE TRIPLICE LABA + LAMA + CSI + PDE SABA o SAMA LABA + CSI TRIPLICE LABA o LAMA LABA + LAMA

15 FEV: 5% - riacutizzazione CAT 9 MRC GOLD 0 S T A D I (A) ICS + LABA o LAMA a opzione LAMA + LABA SABA o SAMA a opzione LAMA o LABA o SABA + SAMA MRC 0 CAT < 0 ICS + LAMA o ICS+LABA+LAMA ICS/LABA+ PDE LAMA+LABA; LAMA + PDE LAMA o LABA a opzione LAMA + LABA MRC + CAT 0 + (B) Riacutizzazioni anno < S T A D I (A) (B) MRC 0 MRC + CAT < 0 CAT 0 + Riacutizzazioni anno < 5

16 FEV: 5% - riacutizzazione CAT 9 MRC FEV: 5% - riacutizzazione CAT 9 MRC S T A D I (A) X MRC 0 CAT < 0 MRC + CAT 0 + (B) Riacutizzazioni anno < S T A D I (A) a opzione SABA o SAMA MRC 0 CAT < 0 MRC + CAT 0 + (B) Riacutizzazioni anno < 95 patients with severe COPD from 0 centres 70%: triple therapy 6

17 % of patients 0//05 Più è severa l ostruzione, maggiori le riacutizzazioni (riacutizzazioni= angina del cardiopatico) NO! slow decliners? (a meno che non siano tali proprio per effetto della terapia) GOLD II (N=95) GOLD III (N=900) GOLD IV (N=9) Hurst JR, et al. N Engl J Med. 00;6:8-8 Un GOLD fast decliner (magari sintomatico) Un GOLD slow decliner / sustainer (magari a- o paucisintomatico)? O GOLD 0 S T A D I (A) ICS + LABA o LAMA a opzione LAMA + LABA SABA o SAMA a opzione LAMA o LABA o SABA + SAMA MRC 0 CAT < 0 ICS + LAMA o ICS+LABA+LAMA ICS/LABA+ PDE LAMA+LABA; LAMA + PDE LAMA o LABA a opzione LAMA + LABA MRC + CAT 0 + (B) Riacutizzazioni anno < 7

18 Odds Ratio for versus 0 Exacerbations 0//05 FEV: 5% - riacutizzazione CAT 9 MRC S T A D Terapia DOM X I (A) (B) MRC 0 MRC + CAT < 0 CAT 0 + Osp. o ricovero Riacutizzazioni anno < FEV: 5% - riacutizzazione CAT 9 MRC S T A D X I (A) (B) MRC 0 MRC + CAT < 0 CAT 0 + Osp. o ricovero Riacutizzazioni anno < ECLIPSE: Factors Associated With Increased Exacerbation Frequency 7 P< N=8 P<0.00 P<0.00 P< P= Exacerbation During Previous Year FEV (per 00 ml decrease) SGRQ Score (per point increase) Positive History for Reflux/Heartburn White Cell Count (per increase of 000/mL) Hurst JR, et al. N Engl J Med. 00;6:8-8. 8

19 FEV: 5% - riacutizzazione CAT 9 MRC S T A D X PI I (A) (B) MRC 0 MRC + CAT < 0 CAT 0 + o ricovero Riacutizzazioni anno < Variante PEPERONE IMBOTTITO Diagnosi precoce (spirometria) Terapia precoce (broncodilatatori first step) Grazie dell attenzione CENSURA Il relatore a 9 mesi Il relatore oggi PDTA CAMPANIA 9