HHE Respiratory 2019 - Page 15

testing or to predict response to inhaled corticosteroid (ICS) in individuals. 2 Key opinion leaders and emerging research suggest that there are disease phenotypes (frequent exacerbator or persistent symptomatic patient). 3 However, the place of inhaled triple therapy (where ‘triple therapy’ refers to use of long-acting beta agonist (LABA), long-acting anti-muscarinic agent (LAMA) and ICS together), asthma–COPD overlap management, role of eosinophils 3 and role of macrolide antibiotics in disease management are also important considerations (which the guideline attempts to address) but require longer term data to further inform future practice. Updates in this guideline have been made on the following: 2 • Investigations, including incidental findings on CT scans – primary care review, advice for patients to return if respiratory symptoms appear, offering smoking cessation and discussing the potential risk of lung cancer • Prognosis – to avoid use of a multidimensional index such as BODE to assess prognosis • Inhaled therapies – to discuss risk of pneumonia and ICS use with patients. Minimising the number and types of inhalers patients use and ensuring they are trained on use • Oral phosphodiesterase 4 inhibitors are mentioned in line with the associated 2017 technology appraisal • Prophylactic antibiotics – recommendations made on (unlicensed) use of azithromycin • Oxygen therapy – eligibility of patients for and risks of prescription (including short burst and ambulatory use) and consideration for use in pulmonary hypertension (noting this is not a treatment for breathlessness and not effective for isolated nocturnal hypoxaemia caused by COPD) • Managing pulmonary hypertension and cor pulmonale – advice on optimised therapies • Lung volume reduction (LVR) surgery and procedures – updated advice to increase uptake/ access • Self-management/exacerbation plans – developed in collaboration with patients and carers. These supplement the existing recommendations on: • diagnosing COPD using symptoms, spirometry and other tests • managing stable COPD using nebulisers, oral therapy and pulmonary rehabilitation • multidisciplinary management of stable COPD, including physiotherapy, occupational therapy, nutrition and palliative care • managing exacerbations of COPD in primary care and in hospital. NICE has produced a visual summary alongside the guidance, covering non-pharmacological management and use of inhaled therapies (Figure 1). They also published concurrent antimicrobial prescribing guidance for acute exacerbations of COPD (December 2018). The 2010 guidance inevitably steered patients towards triple therapy (with LABA, LAMA and ICS) with a greater emphasis on FEV1 (forced expiratory volume in one second) value to guide this. Early therapy started with a short-acting bronchodilator progressing to a single long-acting bronchodilator (evidence subsequently showed superiority of LAMA over LABA use first line, Non- pharmacological measures should be optimised alongside any pharmacological intervention and before escalation of therapy especially in moderate–severe patients due to lower incidence of exacerbations and adverse effects with LAMA); 4,5 stepping up to dual long acting agent and then addition of an ICS (a suggestion which was based on expert opinion). It is now apparent that as a result, some patients were treated with ICS who may not have warranted it. The new guidance still initiates inhaled therapy with a short-acting bronchodilator but progresses to long-acting dual therapy. The new guidance does not rely on FEV1 to adjust therapy. One key change, stepping up after short acting bronchodilator, is the initiation of dual bronchodilator (LABA+LAMA) in preference to a single long acting agent. For patients exhibiting asthmatic features, the dual therapy would be initiated with ICS and LABA rather than LABA/LAMA [‘Where asthmatic features/features suggesting steroid responsiveness in this context include any previous secure diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time (at least 400ml) or substantial diurnal variation in peak expiratory flow (at least 20%)’]. 2 Patients using long-acting therapy outside of the December 2018 recommendations can continue on current treatment and change after review with a healthcare professional (HCP), when both agree is appropriate. NICE is undertaking a separate review on the role of triple therapy in COPD (which was out of scope of the initial guidance update). At time of writing this article, the draft is undergoing public consultation and final guidance is scheduled to be published in Summer 2019. The draft 2019 guidance showed the proposed place of triple therapy in patients who remain breathless +/- exacerbate despite all other interventions being optimised (noting consideration of a three-month trial in those without asthmatic features, reverting if ineffective). 6 Management Management of COPD can be broadly divided into two areas – non-pharmacological and pharmacological. Non-pharmacological These measures should be optimised alongside any pharmacological intervention and before escalation of therapy: • Pulmonary rehabilitation, especially encouraging physical activity to minimise muscle loss/deconditioning (which increases mortality) • Optimised nutrition – dietetic input and supplementation where applicable • Social/occupational therapy input to retain independence and enable activities of daily living • Psychological support for anxiety and depression +/- pharmacological treatment as necessary 7,8 • Airways breathing control techniques to aid energy conservation, management of panic/ anxiety • Use of a hand-held fan may provide relief of breathlessness. 9 Pharmacological • Inhaled therapies initiated appropriate to the stage of disease (Note any patients exhibiting 15 HHE 2019 | hospitalhealthcare.com