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Medicines management: COPD


8 February 2013

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COPD is the fifth biggest killer in the UK, the second most common reason for admission to hospital and costs the NHS almost £1bn a year.1  The current UK prevalence is estimated to be three million. An estimated 900,000 of these people have been diagnosed with COPD and an estimated two million people have COPD that remains undiagnosed.2


The statistics speak for themselves:1

COPD is the fifth biggest killer in the UK, the second most common reason for admission to hospital and costs the NHS almost £1bn a year.1  The current UK prevalence is estimated to be three million. An estimated 900,000 of these people have been diagnosed with COPD and an estimated two million people have COPD that remains undiagnosed.2


The statistics speak for themselves:1

One person dies from COPD every 20 minutes in England resulting in about 23,000 deaths a year. This is almost double the EU average. Of those admitted to hospital with COPD, 15% die within three months and around 25% die within a year of admission.

One in eight people over 35 has COPD that has not been properly identified or diagnosed, and more than 15% are only diagnosed when they present to hospital as an emergency.

80% of people with COPD have at least one other long-term condition. COPD is linked with an increased risk of mortality from cardiovascular disease, and having depression and/or an anxiety disorder.

24 million working days are lost each year from COPD with £3.8 billion lost through reduced productivity.

The challenges
Keeping patients out of hospital is a key priority. An estimated 5% reduction in the number of hospital episodes would lead to an annual saving of £15.5m.2 The newly published NHS companion document An Outcomes Strategy for COPD and Asthma, lists 18 actions that could make a significant difference to the cost and quality of care for people with COPD. Dr Matt Kearney, clinical and public health adviser to the Department of Health respiratory team, highlights three areas where he thinks a focus from commissioners could make a rapid and significant difference.3 Two of these key areas that could benefit from pharmacist-delivered interventions.


1.    Improving Inhaler User.
2.    Smoking Cessation Services.
3.    Improving access to pulmonary rehabilitation.


Inhaler Use – Studies suggest that the majority of people who use inhalers do not do so correctly thus severely limiting drug delivery and effectiveness.1 The current annual primary care prescribing cost for COPD is estimated to be £268.5m.2 Three of the top five items of expenditure in primary care prescribing are inhalers.3


Smoking Cessation – is an important treatment for COPD. It isn’t just a preventative measure.

Spotlight on COPD management to prevent re-admission – A case study
COPD is characterised by airflow obstruction. The airflow obstruction is usually progressive, not fully reversible and does not change significantly over several months. The disease is primarily caused by smoking.4


Exacerbations often occur where there is a rapid and continuous worsening of symptoms beyond normal day-to-day variations requiring a change in treatment.
The aim of the treatment for COPD is to maintain as good as a quality of life as possible, for as long as possible. This includes relieving breathlessness, improving exercise tolerance and reducing the number of exacerbations. The management of individual patients with COPD should be directed by their symptoms and level of disability.

Patient Profile
Name Mr Patel
Age 52
Smoking 20 cigarettes a day
Weight 56kg
Occupation Plumber
History
Mr Patel has smoked 20 cigarettes since he was 15 years of age. He presents with a productive cough which he complains has persisted for the past three weeks. He feels breathless and tired. During the summer he suffered from hayfever and a productive cough during winter. This has been going on for the past two years. He has been diagnosed with COPD.

Management Questions
Question 1. How many pack years are 20 cigarettes from the age of 15 to 52?
Lifetime tobacco exposure is called pack years. A pack year is defined as 20 cigarettes smoked every day for one year. Therefore Mr Patel’s pack year is 37.5

Question 2. Mr Patel’s FEV1 was found to be 59% and FEV1 /FVC to be < 0.7. At what stage of COPD is Mr Patel according to NICE classification 2012?6
Stage 1 (mild) FEV1 > or equal to 80% predicted
Stage 2 (moderate) FEV1 50% to 79% predicted (Correct answer)
Stage 3 (severe) FEV1 30% to 49% predicted
Stage 4 (very severe) FEV 1 <30% predicted

Question 3. What would be the treatment plan and approach for the management of Mr Patel’s COPD?
Stop smoking. This is the single most important piece of advice. Smoking cessation is the only intervention shown to reduce the rate of decline in lung function in COPD patients. Encourage and support patients of all ages who smoke to stop smoking.6,7

Offer NRT, Varniciline (Champix®), bupropion (Zyban®) as appropriate, provided they are not contraindicated, along with a support programme.6

Question 4. Mr Patel is breathless and has exercise limitation. Should you offer him SABA or SAMA first (see Table 1)?
The choice of inhaler device for Mr Patel would depend on the one he can use, and the drug he tolerates best. It also depends on which drug is effective in controlling his symptoms (see Table 2). NICE does not recommend oral corticosteroids reversibility testing to identify patients who will benefit from inhaled corticosteroids.


If Mr Patel is breathless and has exercise limitation, SABA would be the first choice. Prescribe a short-acting beta-2 agonist (SABA — salbutamol or terbutaline) or a short-acting muscarinic antagonist (SAMA — ipratropium bromide) as required to relieve symptoms.6

Question 5a. Mr Patel visits his doctor two months later and remains breathless. What would be your next course of action?
See Figure 1 for the answer.

Question 5b. When would you prescribe Theophylline? 9
a)    Added to inhaled therapy if a patient is symptomatic after a trial of short and long-acting bronchodilators or it’s given to patients unable to use inhaled therapy.9
b)    It should be used with caution in older patients because of differences in pharmacokinetics, increased likelihood of comorbidities, and the use of other medications. It has a narrow therapeutic window.9
c)    Drug interactions should be considered when giving theophylline.9
d)    Dose of theophylline should be reduced when starting medicines that may interact with theophylline e.g. macrolide or quinolone antibiotics.9

Question 5c. Can oral corticosteroids be used as maintenance therapy?6
Do not use oral corticosteroids for maintenance therapy.
Do not use oral corticosteroid reversibility tests to identify patients who will benefit from ICS either.

Question 5d. Do anti-tussives, beta-carotene and prophylactic antibiotics have place in COPD?
They are not recommended by NICE due to lack of evidence:
Anti-oxidant therapy (alpha-tocopherol and beta-carotene), there is no benefit from supplementation with alpha tocopherol or beta-carotene on the symptoms of COPD.7
Anti-tussive therapy – it’s not recommended by NICE due to a lack of data to support their efficacy.7
Prophylactic antibiotics are not recommended.7

Question 6. What are the anticipated problems that might be encountered during Mr Patel’s therapy and management of COPD?6,9
Some of the commonly encountered problems include:
Polypharmacy.
Multiple inhaler devices.
Poor adherence.
Poor inhaler technique.
Poor or lack of communication.

Preventing acute exacerbations and unplanned admissions
The key elements required to achieve this include:
1.    Optimising treatment
    This has been addressed earlier in the case study.
2.    Stop smoking support.
    Evidence-based stop smoking therapy in COPD costs £2,092 per quality-adjusted life year (QALY)  and the effect lasts for decades. Evidence-based stop smoking treatment consists of 90 minutes of intensive support and pharmacotherapy i.e. NRT, Bupropion, and Varenicline.10
3.    Inhaler technique monitoring and coaching
    Patients with COPD should have their ability to use an inhaler device regularly assessed by a competent healthcare professional and, if necessary, should be retaught the correct technique.
4.    Managing exacerbations and supporting self-management planning
   

In general, patients should receive verbal and/or written personalised advice on:
How to recognise the early signs of an exacerbation and respond appropriately.

– Lifestyle and medication issues to prevent exacerbations.
– Discuss and provide written information to all patients with COPD on diet and exercise, and smoking cessation (if necessary).
– For patients who have frequent exacerbations, provide a structured, written action plan on:9
– How to recognise when COPD is getting worse (increased breathlessness, more sputum, coloured sputum, and/or fever).9
– How to initially increase the use of short-acting bronchodilators, and if there is no response, when to contact a primary healthcare professional.
– How should a patient with an acute exacerbation of COPD who is not being admitted in hospital be treated? 9
– Advise the patient to take increased doses or increase the frequency of use of short-acting bronchodilators, for example by doubling the dose or frequency of use.
– Advise the patient to keep to the same delivery system (inhaler with spacer or nebuliser) during an exacerbation as is used on a day-to-day basis, if possible. Explain that both delivery systems (inhaler and spacer or nebuliser) are equally effective, and hospitals use nebulisers mainly for convenience.9
– Recommend using a spacer device if a person does not usually use one, as they may find it easier to use and it will help to deliver a maximum dose.
– If the patient is likely to become fatigued, a nebuliser may be more appropriate.
Prescribe systemic corticosteroids prednisolone 30mg orally once daily for 7–14 days if a patient gets a significant increase in breathlessness that interferes with daily activities. Consider osteoporosis prophylaxis for people requiring frequent courses of oral corticosteroids.9
– Self-management plans should also provide written advice for patients that have a supply of medication at home, advising them:9
– On how to start oral corticosteroid therapy if their increased breathlessness interferes with activities of daily living.
– On how to start antibiotics if sputum becomes discoloured or increases in volume.
– And to contact their GP or healthcare professional if they start treatment or are uncertain about whether to start treatment.


Prescribe oral antibiotics for patients with a history of more purulent sputum
or clinical signs of pneumonia. Consult local antibiotic prescribing guidelines. Initial recommended treatment should usually be:
– Amoxicillin 500mg three times daily for five days or a tetracycline (for example doxycycline 200mg on the first day then 100mg once daily, for a total of five days).11 Prescribe a macrolide (for example erythromycin 500mg four times daily or clarithromycin 500mg twice daily for five days), if the patient is allergic to penicillin and doxycycline is contraindicated.9
– Prescribe co-amoxiclav 625mg three times daily for 5 days. If the patient has antibiotic resistance risk factors (comorbid disease, severe COPD, frequent exacerbations, or antibiotic use in the past three months).9
– Mucolytic therapy can be considered in patients if symptoms continue, however,  do not use to prevent exacerbations.9

Conclusion
COPD management is a game of influencing behavioural change, managing exacerbations and ensuring correct and optimal use of inhalers.


Management plans should be underpinned and supported by a clear follow-up strategy with routine monitoring of the effectiveness of inhaled therapy and theophylline.9 Existing services such as Medicines Use Reviews (MUR’s), New Medicines Service (NMS) and ‘Healthy Outlook’ – a newly launched pharmaceutical service which claims the potential to save the NHS £1,960 for each avoided COPD emergency admission12, can be leveraged to help drive the health outcomes and reduce the costs of management. l

Further Reading
NHS UK. First Steps in COPD.
Available at: www.improvement.nhs.uk/documents/First_Steps_in_COPD.pdf

References
1.    An Outcome Strategy for COPD and Asthma: NHS Companion Document. May 2012. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_134000
2.    Chronic Obstructive Pulmonary Disease: Costing Report – Implementing NICE Guidance. National Institute for Health & Clinical Excellence. February 2011. Available at: www.nice.org.uk/nicemedia/live/13029/53292/53292.pdf
3.    Clearing Obstructions. Health Service Journal Supplement 2012;2-3.
4.    NICE. Guidelines. Chronic Obstructive Pulmonary Disease Clinical Guideline. 2004.
5.    Smoking Pack years calculator. Available at: http://smokingpackyears.com/pda.
6.     NICE. CG 101 Quick Reference. Available at: www.nice.org.uk/nicemedia/live/13029/49399/49399.pdf
7.    NICE. COPD Up Date Evidence. Page 233.
    Available at: www.nice.org.uk/nicemedia/live/13029/49425/49425.pdf.
8.    MHRA Drug Safety update. November 2008. Available at: www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON087928
9.    CKS. COPD. Available at: www.cks.nhs.uk/chronic_obstructive_pulmonary_disease/management/scenario_stable_copd/drug_treatment/inhaled_treatments_fev1_50_predicted_or_greater
10. Hoogendern M, et al.  Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD. Thorax         2010;65:711-718.
11.  Health Protection Agency. Available at: www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/PrimaryCareGuidance
12. News article. The Pharmaceutical Journal. 3 November 2012 (Vol 289); page 482. Available at: www.pjonline.com/news/healthy_outlook_pharmacy_service_for_copd_patients_launched

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