Reed: The past, present, and future of COPD

Today we have a talk that Dr. Robert Reed gave at a 2015 Maryland Pulmonary Medicine Conference. Dr. Reed is a Associate Professor of Medicine here at the University of Maryland and the current Medical Director of Lung Transplantation at the Veterans Administration Southeast Region. This talk was SO educational and useful that we begged him for the opportunity to share this knowledge. Thankfully he agreed! So sit back and prepare to have a concentrated 40 minutes of COPD pearls and a fantastic discussion on just how well we do with lung transplants!

Clinical Pearls

COPD exacerbation:

  • Can be costly to both the healthcare system and the work force
  • No true definition, as GOLD and CCRN both have variable requirements
    • However, the exacerbation is the leading cause of morbidity and mortality in COPD

Studies:

  • ISOLDE (2000)- Fluticasone vs placebo
    • Inhaled corticosteroids (ICS) = lower rates of exacerbations (30-33% reduction in events (p=0.026)
    • When you look at the ISOLDE run in (1999)
      • 8 week d/c of ICSs leading to a 38% rate of exacerbations vs. only 6% in those NEVER on ICSs
  • COPE (2002)- determined that stopping ICS was associated with increased risk of exacerbation
  • TORCH (2007)- Salmeterol, Fluticasone, Combo, vs. Placebo
    • Trend towards improved survival with use of combo drugs
  • INSPIRE (2008)- SFC vs Tiotropium
    • Adherence, PNA rates (SFC>T) w/ exacerbations equal (SFC=T)
      • However, rate of death SFC<T
  • UPLIFT (2008)- Tiotropium vs. placebo as add-on (2/3 were on LABA/ICS combo)
    • Tiotropium = less exacerbation + less death
  • NETT (2014)- compare long term steroids vs. none
    • Higher mortality when using long term oral steroids
  • Summary
    1. ICS reduces exacerbation, withdrawal my trigger (ISOLDE, COPE)
    2. Exacerbation reduction: LAMA>LABA, LAMA=SFC (INSPIRE)
    3. SFC increases PNA, but may improve survival (TORCH, INSPIRE)
    4. LAMA is an effective add-on therapy to SFC (UPLIFT)
    5. Avoid ICS alone (TORCH) 
    6. Avoid chronic PO steroids (NETT post-hoc)

Combined assessment of COPD

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  • When assessing the risk, choose the highest risk according to GOLD grade or exacerbation history
    • The best predictive measure for an exacerbation is a prior exacerbation

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©2014: Global Initiative for COPD

Transplant

  • COPD is #1 historically (IPF is #1 currently in the USA)
  • Dependent on the BODE
    • BMI, airflow Obstruction, Dyspnea, Exercise capacity
    • Will establish the median survival expected
      • Agreed upon by multiple review articles, but survival benefit is disputable
  • Multiple contraindications: #1+#2: atherosclerotic disease + malignancy
    • UNOS data suggests that the BODE data is not predictive of the true mortality IF we properly choose patients

Suggested Reading

  1. Celli BR, Cote CG, Marin JM, Casanova C, Montes de Oca M, Mendez RA, Pinto Plata V, Cabral HJ. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004 Mar 4;350(10):1005-12.[NEJM Link]
  2. Vogelmeier C, Hederer B, Glaab T, Schmidt H, Rutten-van Mölken MP, Beeh KM, Rabe KF, Fabbri LM; POET-COPD Investigators. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. N Engl J Med. 2011 Mar 24;364(12):1093-1103.[PubMed Link]
  3. Erbland ML, Deupree RH, Niewoehner DE. Systemic Corticosteroids in Chronic Obstructive Pulmonary Disease Exacerbations (SCCOPE): rationale and design of an equivalence trial. Veterans Administration Cooperative Trials SCCOPE Study Group. Control Clin Trials. 1998 Aug;19(4):404-17.[PubMed Link]
  4. Leuppi JD, Schuetz P, Bingisser R, Bodmer M, Briel M, Drescher T, Duerring U, Henzen C, Leibbrandt Y, Maier S, Miedinger D, Müller B, Scherr A, Schindler C, Stoeckli R, Viatte S, von Garnier C, Tamm M, Rutishauser J. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA. 2013 Jun 5;309(21):2223-31.[PubMed Link]
About the Author

Jim Lantry

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Just your average critical care doc: Wandering the ED and ICUs for the USAF down in the San Antonio Military Medical Center, traveling the globe to cannulate for ECLS wherever the need arises, and trying to keep up with great minds of today. E: JlantryMD@gmail.com

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