of COPD
Zen Ahmad
Medical Faculty, Sriwijaya University
COPD IS A MAJOR BURDEN ON HEALTHCARE
RESOURCES AND THE ECONOMY
COPD is a leading cause of morbidity and mortality
COPD affects 384 million people worldwide (2010)1 and
causes 3 million deaths annually (5% of all deaths
worldwide)2
It is predicted to become the third leading cause of global
mortality by 20303
The economic burden of COPD is high, with costs increasing
as the disease progresses
Severe COPD costs are up to 17 times higher than mild COPD4
High costs are associated with treatment of exacerbations and loss of
productivity in the workplace 4
1. Diette GB, Orr P, McCormack MC et al. Population Health Management 2010;13:21-26.
2. WHO. COPD Fact Sheet No 315. 2011. Available from www.who.int/mediacentre/factsheets/fs315/en/index.html
3. WHO. Chronic respiratory diseases. Accessed 2011. http://www.who.int/respiratory/copd/burden/en/index.html
4. Wouters EFM. Respir Med 2003;97:S3-S14.
GOLD Guideline
Definition of COPD
Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global
Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from www.goldcopd.org
Risk Factors for COPD
Nutrition
Infections
Socio-economic
status
Aging Populations
Gene, Gender, Comorbidities
COPD has pulmonary and systemic components
Inhaled substances +
Genetic susceptibility
Airway limitation
Chemotactic factors
IL8; CXC chemokines
LTB4
TGFβ
CTG
RISK FACTORS
SYMPTOMS
Host factors
Dyspnea
Chronic cough + Tobacco
Occupational hazards
Sputum production
Indoor/outdoor pollution
Spirometry;
The presence of FEV1/FVC < 0.70 confirms the presence
of the persistent airflow limitation and thus of COPD.
Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease
(GOLD) 2017. Available from www.goldcopd.org
ABCD assessment of COPD
The ABCD assessment grid has been refined to utilize exclusively
respiratory symptoms and exacerbation history to assign categories
PATIENT CHARACTERISTICS
Reduce mortality
MANAGEMENT PLAN
Adapted from:
1. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD)
2016. Available from www.goldcopd.org
2. Postma D, Anzueto A, Calverley P et al . Prim Care Respir J 2011; 20:205-209.
Management of COPD Non-
pharmacological
Management of COPD (pharmacologic)
Anti
cholinergics
SAMA
LAMA
PDE4 inhibitors
Antibiotics
Mucolytics COPD
Immunoregulators
Others
Pharmacologic algorithm (GOLD group)
Grup C Grup D
Consider roflumilast if FEV1 < 50% Consider macrolide
LABA + ICS pred. and patient has chronic (in former smokers)
LAMA+LABA bronchitis
Further exacerbation(s)
LAMA+LABA+ICS
Further Persistent
Exacerbation(s) symptoms/further
Further
exacerbation(s)
Exacerbation(s)
LAMA LABA
LAMA LAMA+LABA
+ ICS
Grup B
Grup A
Continue, stop or try LAMA+LABA
alternative class of
bronchodilator
Persistent Symptoms
Evaluate effect
A long-acting bronchodilator
A bronchodilator (LABAor LAMA )
@2017 Global Initiative for Chronic Obstructive Lung Disease, all rights reserved. Use is by express license from the owner
ICS/LABA pada PPOK
LABA/ICS dapat menjadi pilihan pertama pada pasien
• Riwayat dan/atau diketahui Asthma-COPD Overlap (ACO)
• Pasien dengan eosinofil tinggi pada darah
GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD. Available online at http://goldcopd.org/. Accessed 21stNovember 2016.
Penggunaan ICS/LABA pada PPOK
Ada bukti yang menunjukkan terjadi penurunan FEV1 (~ 40 mL) ketika ICS
dihentikan, yang dapat dikaitkan dengan peningkatan kadar Eosinofil.
GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD. Available online at http://goldcopd.org/. Accessed 21stNovember 2016.
Corticosteroid
• ICS/LABA is more effective than monotherapy in improving
lung function and health status; reducing exacerbations in
patients with exacerbations, moderate-very severe COPD
• Regular treatment with ICS increases the risk of pneumonia
especially in those with severe disease
• Triple inhaled therapy of ICS/LAMA/LABA improve lung
function, symptoms and health status and reduces
exacerbations compared to ICS/LABA or LAMA monotherapy
• Long term use of oral steroids has numerous side effects with
no evidence of benefit
Problem pada PPOK
Partridge, Martyn R., et al., Effect on lunch function and morning activities of Budesonide/formoterol versus salmeterol/fluticasone in patients
with COPD. Ther Adv Respir Dis (2009), 3(4); 147-157
Partridge, Martyn R., et al., Effect on lunch function and morning activities of Budesonide/formoterol versus salmeterol/fluticasone in patients
with COPD. Ther Adv Respir Dis (2009), 3(4); 147-157
19
Desain penelitian
Random, buta ganda, multi-centres, double-dummy, cross-over, 442 pasien dengan PPOK usia ≥40 tahun (Prebronkodilator
FEV1 ≤ 50%; FEV1/VC <70%) dengan 2x periode pengobatan 1 minggu, dilakukan dalam 66 pusat di 9 negara
(Argentina, Australia, Belgium, Brazil, Denmark, Jerman, India, Filipin, dan UK
Partridge, Martyn R., et al., Effect on lunch function and morning activities of Budesonide/formoterol versus salmeterol/fluticasone in patients
with COPD. Ther Adv Respir Dis (2009), 3(4); 147-157
PEF 5 menit setelah dosis:
Budesonide/Formoterol 15.1 L/menit
Salmeterol/Fluticasone 14.2 L/menit
P = 0.603
Partridge, Martyn R., et al., Effect on lunch function and morning activities of
Budesonide/formoterol versus salmeterol/fluticasone in patients with COPD. Ther
Adv Respir Dis (2009), 3(4); 147-157
Budesonide/Formoterol lebih signifikan
menunjukkan perbaikan aktivitas pagi hari
Vs. Sal/Flu
Partridge, Martyn R., et al., Effect on lunch function and morning activities of Budesonide/formoterol versus salmeterol/fluticasone in patients
with COPD. Ther Adv Respir Dis (2009), 3(4); 147-157
**P<0.0001
*P=0.0003
• Kejadian eksaserbasi per 100 pasien/tahun pada pasien PPOK yang diobati dengan BUD/FORM (n=2734) atau FLU/SAL (n=2734)
• Jumlah rata – rata penggunaan pelayanan kesehatan disesuaikan dibandingkan dengan menggunakan analisis regresi poisson.
**P<0.0001; *P=0.0003 for difference.
• CI, confidence intervals; BUD/FORM, budesonide/formoterol; FLU/SAL, fluticasone/salmeterol
Larrson, K., et al., J of Int Med, 2013, 273; 584-594
Bud/Formoterol memiliki onset
kerja lebih cepat daripada Sal/Flu,
sehingga lebih cepat dalam
meredakan gejala akut.
Efek samping pneumonia pada ICS dikonfirmasi berdasarkan studi ICS yang
menggunakan Flutikason furoate, bahkan pada dosis rendah.
Pada penelitian dengan pasien COPD moderate, ICS monoterapi atau dalam
kombinasi LABA tidak meningkatkan resiko pneumonia
GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD. Available online at http://goldcopd.org/. Accessed 21stNovember 2016.
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