Gerichte therapie bij Astma COPD overlap syndroom Dr. Tobias Bonten AIOS Huisartsgeneeskunde, Postdoc en Epidemioloog Longziekten en Public Health & Eerstelijns Geneeskunde LEIDS UNIVERSITAIR MEDISCH CENTRUM Disclosure belangen spreker (potentiële) belangenverstrengeling Geen 1
GERICHTE BEHANDELING 3 Achtergrond Astma vs. COPD Astma COPD Risico factor Atopie (allergie) Roken / lucht verontreiniging Leeftijd Symptomen Alle (meestal begin <20) Hoesten Ja Ja Slijm Niet vaak Vaak Meestal >40 Adem geluiden Piepen Piepen, gereutel Kortademigheid Wisselend Persisterend (exacerbaties) Prognosis Stabiel, normale levensverwachting Progressief, verminderde levensverwachting 4 2
Achtergrond Asthma vs. COPD Diagnose Laboratorium Pulmonary function Asthma Allergie (IgE, eosinophielen) Normaal of reversibele obstructie COPD Geen Irreversibele obstructie Achtergrond Astma EN COPD? Astma COPD overlap syndroom (ACOS)? 3
ACOS? 1. GINA/GOLD (guideline) List 9 features: 4. Spanish similar COPD number consensus of asthma document and COPD features ACOS more 5. Czech - Major likely; Pneumological spirometry criteria: and recommended Physiological Society - Major - criteria: Increase FEV1 15% and 400ml - - Increase Eosinophilia FEV1 15% and 400ml - - Positive History provocation of asthma test 2. Australian - - Minor Asthma FeNOcriteria: 45-50 management ppb and/or sputum Handbook eosinophils 3% Pooling of features - - History Total corresponding of IgE asthma to asthma and COPD, followed by a trial - of Minor Inhalation - criteria: Atopy Corticosteroids - FEV1 12% and 200ml - 2 ocassions: FEV1 12% and 200ml - Total IgE - Atopy and COPD diagnosis 3. Japanese ACOS Respiratory if Society COPD guidelines Asthma component: ACOS if2 major paroxysmal dyspnoea, cough and wheeze worse at night 2 and major 1 major early + morning, 2 minor atopy, sputum/blood 1 major + 2 minor eosinophilia. Gibson PG, et al. Thorax 2015 ACOS fenotypen? CHAOS instead of ACOS? Bateman, Lancet Respir Med 2015 4
Overzicht 1. Is ACOS klinisch relevant? 2. Hoe vaak komt ACOS voor? 3. Identificeren van ACOS in de eerste lijn 4. Adviezen over behandeling van ACOS 9 Insert > Header & footer Overzicht 1. Is ACOS klinisch relevant? 2. Hoe vaak komt ACOS voor? 3. Identificeren van ACOS in de eerste lijn 4. Adviezen over behandeling van ACOS 10 Insert > Header & footer 5
ACOS klinisch relevant? Frequency of exacerbations among ACOS patients is higher than in Asthma or COPD Nielsen M, et al. Int J COPD 2015 ACOS klinisch relevant? Eigen onderzoek bij 864 patienten met Astma/COPD 1. COPD AND Asthma in registry 2. COPD AND Asthma in registry OR ACOS as text in EMR 3. Self-reported COPD AND Asthma 4. FEV1/FVC < 0.7 AND 10 pack-years AND asthma <40 years 5. COPD in registry OR self-reported + FEV1/FVC < 0.7 AND Asthma in registry OR Self-reported 6. COPD in registry OR Self-reported + FEV1/FVC < 0.7 AND Asthma in registry OR Self-reported OR FENO 45 ppb 6
ACOS klinisch relevant? 864 patiënten met Astma/COPD Follow-up 1.8jr Exacerbatie: voorschrift corticosteroid of antibioticum door huisarts * adjusted for: age, sex, bmi, current smoking, FEV1/FVC ratio at baseline, ICS use, number of exacerbations in previous year ACOS klinisch relevant? * adjusted for: age, sex, bmi, current smoking, FEV1/FVC ratio at baseline, ICS use, number of exacerbations in previous year 7
ACOS klinisch relevant? Survival is worse among ACOS patients than in Asthma or COPD, depending on age of asthma onset Lange P, Lancet Resp Med 2016 ACOS relevant for society? Gerhardsson de Verdier M, Val Health 2015 8
Overzicht 1. Is ACOS klinisch relevant? 2. Hoe vaak komt ACOS voor? 3. Identificeren van ACOS in de eerste lijn 4. Adviezen over behandeling van ACOS 17 Insert > Header & footer Eerdere studies Karakteristieken en ACOS prevalentie Study Population Age Prevalence (%) Definition Brzostek Smoking >45 100 Doctor diagnosed asthma + COPD Fu Asthma, COPD, ACOS >55 55.5 Symptoms, flow variability, incomplete reversible obstruction Lee Asthma, ACOS 41-79 37.9 Asthma with incomplete reversible obstruction Milanese Asthma 65 28.8 Asthma and chronic bronchitis and/or impaired diffusion Miravitles COPD, ACOS 40-80 17.7 COPD (FEV1/FVC <0.7) and doctor diagnosed asthma <40yr Kauppi Asthma, COPD, 18-75 14.5 Doctor diagnosed asthma + COPD ACOS (FEV1/FVC <0.7) Hardin COPD, ACOS 45-80 12.6 COPD with self-reported asthma <40yr de Marco General 20-84 1.6-4.5 Doctor diagnosed asthma + COPD Pleasants General 18-74 3.3 Self-reported COPD and asthma Chung General >19 2.3 FEV1/FVC <0.7 + self-reported wheezing history Menezes General >40 1.8 Asthma (symptoms+spirometry / selfreported) and COPD (FEV1/FVC <0.7) Nielsen M, et al. Int J COPD 2015 9
Eerdere studies Karakteristieken en ACOS prevalentie Study Population Age Prevalence (%) Definition Brzostek Smoking >45 100 Doctor diagnosed asthma + COPD Fu Asthma, COPD, ACOS >55 55.5 Symptoms, flow variability, incomplete reversible obstruction Lee Asthma, ACOS 41-79 37.9 Asthma with incomplete reversible obstruction Milanese Asthma 65 28.8 Asthma and chronic bronchitis and/or impaired diffusion Miravitles COPD, ACOS 40-80 17.7 COPD (FEV1/FVC <0.7) and doctor diagnosed asthma <40yr Kauppi Asthma, COPD, 18-75 14.5 Doctor diagnosed asthma + COPD ACOS (FEV1/FVC <0.7) Hardin COPD, ACOS 45-80 12.6 COPD with self-reported asthma <40yr de Marco General 20-84 1.6-4.5 Doctor diagnosed asthma + COPD Pleasants General 18-74 3.3 Self-reported COPD and asthma Chung General >19 2.3 FEV1/FVC <0.7 + self-reported wheezing history Menezes General >40 1.8 Asthma (symptoms+spirometry / selfreported) and COPD (FEV1/FVC <0.7) Nielsen M, et al. Int J COPD 2015 Eigen onderzoek bij 864 patienten met Astma/COPD Total population Prevalence Asthma/COPD population ACOS Definition n = 5647 n = 846 1 COPD AND Asthma in registry 1.2 10.3 2 COPD AND Asthma in registry OR ACOS as text in EMR 1.2 10.3 3 Self-reported COPD AND Asthma 0.5 4.4 4 FEV1/FVC < 0.7 AND 10 pack-years AND asthma <40 years 0.6 4.7 5 COPD in registry OR self-reported + FEV1/FVC < 0.7 AND Asthma in registry OR Self-reported 6 COPD in registry OR Self-reported + FEV1/FVC < 0.7 AND Asthma in registry OR Self-reported OR FENO 45 ppb 1.1 9.1 4.9 38.2 20 Bonten TN et al: Defining Asthma COPD overlap syndrome: a population based study. ERJ 2017, accepted for publication 10
Overzicht 1. Is ACOS klinisch relevant? 2. Hoe vaak komt ACOS voor? 3. Identificeren van ACOS in de eerste lijn 4. Adviezen over behandeling van ACOS 21 Insert > Header & footer ACOS? 11
Simpeler oplossing? Bij patiënten met COPD ACOS 1: Spaanse consensus criteria versus ACOS 2: Alleen astma < 40 jaar, diagnosed only on the basis of a history of asthma before the age of 40 years Barrecheguren, Int J COPD 2015 Prevalentie Barrecheguren, Int J COPD 2015 12
Conclusie Simpeler oplossing voor eerste lijn? Patients diagnosed with ACOS in COPD on the basis of a previous diagnosis of asthma before the age of 40 years are very similar to patients diagnosed with ACOS by the more restrictive criteria proposed by the Spanish consensus. Therefore, the previous diagnosis of asthma before 40 years of age in a patient with COPD can be used as a presumptive diagnosis of ACOS. Barrecheguren, Int J COPD 2015 Overzicht 1. Is ACOS klinisch relevant? 2. Hoe vaak komt ACOS voor? 3. Identificeren van ACOS in de eerste lijn 4. Adviezen over behandeling van ACOS 26 Insert > Header & footer 13
ACOS relevant voor behandeling? Timing van ICS Asthma: ICS= step 1-2 COPD: ICS= step 3 STEP 5 STEP 1 STEP 2 Low dose ICS STEP 3 Low dose ICS/LABA* STEP 4 Med/high ICS/LABA Refer for add-on treatment e.g. anti-ige Consider low dose ICS Leukotriene receptor antagonists (LTRA) Low dose theophylline* As-needed short-acting beta 2 -agonist (SABA) Med/high dose ICS Add tiotropium# Low dose ICS+LTRA High dose ICS (or + theoph*) + LTRA (or + theoph*) As-needed SABA or low dose ICS/formoterol** Add tiotropium# Add low dose OCS 27 GINA-GOLD 14
GINA-GOLD: treatment ACOS Initial treatment: - Patients with features of asthma: receive adequate controller therapy including inhaled corticosteroids, but not long-acting bronchodilators alone (as monotherapy) - Patients with features of COPD: receive appropriate symptomatic treatment with bronchodilators or combination therapy, but not inhaled corticosteroids alone (as monotherapy). www.ginaasthma.org Hoe behandelen NL huisartsen patiënten met ACOS? Characteristic 1 2 3 4 5 6 COPD in registry + Asthma in registry COPD in registry + Asthma in registry OR ACOS as text in electronic record COPD self-reported + Asthma self-reported FEV1/FVC < 0.7 + 10 pack-years + asthma <40 years COPD in registry OR Self-reported AND FEV1/FVC < 0.7 + Asthma in registry OR Self-reported COPD in registry OR Self-reported OR FEV1/FVC < 0.7 + Asthma in registry OR Self-reported OR FENO 45 Medication use SABA 15 15 29 42 22 20 LABA 6 6 6 0 1 4 LAMA 13 13 17 6 15 9 ICS 13 13 18 33 23 15 Combination LABA+ICS 45 45 56 38 48 40 Bonten TN et al: Defining Asthma COPD overlap syndrome: a population based study. ERJ 2017, accepted for publication 30 15
Take home messages 1. Is ACOS klinisch relevant? Hogere kans op exacerbaties dan astma patiënten, hogere mortaliteit 2. Hoe vaak komt ACOS voor? ± 10% in 1 e lijns astma/copd populatie 3. Identificeren van ACOS in de eerste lijn: voorgeschiedenis van astma/symptomen bij COPD er, bij hoge ziektelast verwijzen naar longarts voor diagnostiek 4. Adviezen over behandeling van ACOS: ICS afhankelijk van klachtenpatroon. Eenmalige verwijzing naar longarts voor diagnostiek en behandeladvies? 31 Dankwoord Leiden University Medical Center study team Prof. Niels Chavannes Prof. Christian Taube Prof. Pieter Hiemstra Dr. Marise Kasteleyn 32 Insert > Header & footer 16
Evt. extra slides 33 Insert > Header & footer Defining ACOS Patient examples Postma DS, Rabe KF. N Engl J Med 2015;373:1241-1249. 34 Insert > Header & footer 17
Defining ACOS Postma DS, Rabe KF. N Engl J Med 2015;373:1241-1249. 35 18