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
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
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
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
Ass. %teor. FEV.78 FVC.5 8 IT FVC 8 5
Ass. %teor. FEV. 0 FVC.77 06 IT FVC 87 Ass. %teor. FEV.6 80 FVC. 8 IT FVC 80 6
Ass. %teor. FEV.50 6.5 FVC.65 6.5 IT FVC 90.5 Ass. %teor. FEV.50 6.5 FVC.65 6.5 IT FVC 90.5 Nonostante la terapia (!) la paziente peggiora notevolmente, rapidamente, in pochi mesi e viene a consulto 7
Ass. %teor PRIMA UIP DOPO FEV 0.9 6 FVC. 67.6 IT 7 All EO: VELCRO BIBASILARE PRIMA Ass. %teor. DOPO Ass. %teor. PRIMA Ass. %teor. DOPO Ass. %teor. FEV.50 6.5 FEV 0.9 6 FEV.50 6.5 FEV 0.9 6 FVC.65 6.5 IT 90.5 FVC. 67.6 IT 7 FVC.65 6.5 IT 90.5 FVC. 67.6 IT 7 8
Lancet Respir Med. 0 Nov;():869-7 9
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
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.
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
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%
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
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
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
% of patients 0//05 Più è severa l ostruzione, maggiori le riacutizzazioni (riacutizzazioni= angina del cardiopatico) 50 0 7 NO! 0 0 8 slow decliners? (a meno che non siano tali proprio per effetto della terapia) 0 7 0 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
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<0.00 6 5.7 5 N=8 P<0.00 P<0.00 P<0.00.07 P=0.00..07.08 0 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
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