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					  COPD: MANAGEMENT OF STABLE DISEASE
          AND EXACERBATIONS


                 Dennis E. Doherty, M.D.
                  Professor of Medicine
Chief, Division of Pulmonary and Critical Care Medicine
Co-chairman, National Lung Health Education Program

       University of Kentucky Medical Center
  Lexington Veterans Administration Medical Center
      OBJECTIVES



• Historical Perspective
• Mechanisms of Airflow Obstruction
• Treatment Modalities
MECHANISMS OF AIRFLOW OBSTRUCTION
             IN COPD
     PERIPHERAL ADRENERGIC ACTIONS

                 Alpha             Beta1             Beta2

Smooth     Bronchoconstriction                 Bronchodilation
Muscle     Urinary Retention                   Uterine Relaxation

                                 Tachycardia
Heart                            Arrhythmias


Skeletal                                       Tremor
Muscle


Vascular   Hypertension                        Dilatation
MECHANISMS OF BRONCHODILATION
   BETA2-ADRENERGIC AGENTS

              Beta2-selective
             Adrenergic Agents




                Adenylyl
                 Cyclase

                  ATP
    cAMP                         cAMP




           BRONCHODILATION
                                 Drawing by Dennis E. Doherty, MD
MECHANISMS OF AIRWAY OBSTRUCTION




                           Drawing by Dennis E. Doherty, MD
Muscarinic Receptor Subtypes in Airways


                     CNS       Vagal Parasympathetic (X)



       Parasympathetic
           Nerves
                             M 2 RECEPTORS
                             Inhibit Ach Release


             Acetylcholine


                                Acetylcholine


                    M 3 RECEPTORS



           AIRWAY SMOOTH MUSCLE CELLS
                  MUCUS GLANDS
                                                   Drawing by Dennis E. Doherty, MD
Drawing by Dennis E. Doherty, MD
MECHANISMS OF BRONCHODILATION
   ANTICHOLINERGIC AGENTS
           CHOLINERGIC M


                                 Ipratropium Bromide
                                        Atropine

      Increased
     Cyclic GMP
                                                          Acetyl-
             Calcium   M3                X             Choline (ACh)
                                     CHOLINERGIC
                                      RECEPTOR



                       Calcium




                            Decreased Smooth Muscle
                            Constriction and
                            Mucus Gland Secretion



                                         Drawing by Dennis E. Doherty, MD
DISTRIBUTION OF CHOLINERGIC AND
     ADRENERGIC RECEPTORS




Parasympathetic      Sympathetic
                                   Treatment of COPD

                        CHRONIC
                       BRONCHITIS                                      EMPHYSEMA




                   AIRFLOW
                 OBSTRUCTION




                                                              ASTHMA


American Thoracic Society. Am J Respir Crit Care Med. 1995.
PREVENT EMPHYSEMA
 CHRONIC MANAGEMENT OF COPD
     (GOLD Guidelines Am J Respir Crit Care Med 2001;163:1256-1276)




   Diagnose          Education          Spirometry

                             Smoking cessation
   Reduce          Education Immunize
    Risk                     Reduce other exposures


                                   Bronchodilators
   Reduce           Education
                                   Consider inhaled steroids
  Symptoms
                                   Pulmonary rehabilitation

  Reduce               Education        Consider oxygen
Complications                           Treat exacerbations
 STEPWISE TREATMENT OF COPD BASED ON SEVERITY
            (GOLD Guidelines Am J Respir Crit Care Med 2001;163:1256-1276)




Stage 0:                                            • Avoid Risks
                    • Normal spirometry             • Vaccinate
At Risk
Stage I:            • FEV1/FVC < 70%                • Add a short-acting bronchodilator prn
Mild COPD           • FEV1 > 80% predicted          – Anticholinergic or
                                                    – Beta2-agonist

Stage IIA:          • FEV1/FVC < 70%                • Add one or more short-acting
                    • IIA: 50% < FEV1 < 80%         bronchodilators on a scheduled basis
Moderate COPD
                                                    (Anticholinergic + Beta2-agonist)

Stage IIB:          • FEV1/FVC < 70%                • Consider trial of inhaled steroids
Moderate COPD       • IIB: 30% < FEV1 < 50%         • Add Pulmonary Rehabilitation

Stage III:          •FEV1/FVC < 70%                 • Evaluate for adding oxygen
Severe COPD         •FEV1 < 30%                     • Consider surgical options
  NATIONAL LUNG HEALTH
EDUCATION PROGRAM (NLHEP)


         A new national healthcare
         initiative aimed at the
         diagnosis of early stages of
         COPD and related disorders.


 • TEST YOUR LUNGS
 • KNOW YOUR NUMBERS
                               www.nlhep.org
OFFICE SPIROMETERS
                                   Treatment of COPD

                        CHRONIC
                       BRONCHITIS                                      EMPHYSEMA




                   AIRFLOW
                 OBSTRUCTION




                                                              ASTHMA


American Thoracic Society. Am J Respir Crit Care Med. 1995.
    OBJECTIVES FOR INTERVENTIONS
IN THE CHRONIC MANAGEMENT OF COPD


 •   Improvement in Lung Function
 •   Improve Quality of Life (Healthcare Status)
 •   Relieve Symptoms
 •   Decrease Exacerbations
 •   Decrease Hospitalizations
 •   Decelerate Decline in Lung Function
 •   Increase Life Expectancy
 •   Achieve Objectives in a Cost-Effective Manner
First Line Therapy in COPD is

        Preventative

      AVOID TOBACCO
          GOLD Guidelines
 (GOLD Guidelines Am J Respir Crit Care Med 2001;163:1256-1276)




  Bronchodilation is first-line
pharmacologic therapy in COPD
    PHARMACOLOGIC ARMAMENTARIUM

•   Anticholinergics (Parasympatholytic)
     •   Short-acting inhaled (Ipratropium)
     •   Long-acting (Tiotropium)

•   Beta Agonists (Sympathomimetic)
     •   Short-acting inhaled (numerous available)
     •   Long-acting inhaled (Salmeterol, Formoterol)

•   Methylxanthines (Sympathomimetic)

•   Anti-Inflammatory
     •   Oral Steroids
     •   Inhaled Steroids
     •   Other anti-inflammatory agents (data pending)
    ANTICHOLINERGICS AND SHORT-ACTING BETA-AGONISTS
                 ENHANCE FEV1 IN COPD
.




                                                     Test Day 85
                                                                Albuterol (N=165)
           % Change in mean FEV1


                                   30                           Ipratroprium (N=176)

                                   25

                                   20

                                   15

                                   10

                                    5

                                    0
                                        0   1    2      3   4      5     6      7      8
                                                Hours After Test Dose

                                                                               Chest 105:1411, 1994
     LONG-ACTING INHALED BETA AGONISTS


•   Duration: Bronchodilation lasts for up to 12 hours

•   Peak action: Fomoterol (30 min), onset within 5 min
    Salmeterol (1-2hr), not indicated for exacerbations

•   Most helpful:
    – Non-compliant patients (less frequent dosing)
    – Nocturnal component of COPD
•   ? Of cost-benefit compared to short-acting beta-agonists
                       SALMETEROL IN COPD
                       (Mahler et al, Chest 115:957, 1999)




                                                               Placebo
                                                             Salmeterol
                                                             Ipratopium
Change from Baseline
        FEV1
                      SALMETEROL IN COPD
                        (Mahler et al, Chest 115:957, 1999)



•   For patients ‘non-responsive’ to albuterol, (n=145, 35% ), ipratropium lead to
    greater bronchodilation compared to other treatments

•   The mean transitional dyspnea index was significantly improved vs placebo
    and not significantly different for salmeterol vs ipratropium

•   Ipratropium lead to a significantly improved 6 min walk vs placebo whereas
    salmeterol did not

•   Night time dyspnea was improved with salmeterol treatment

•   Overall, ipratropium lead to a greater reduction in dyspnea related to activities
    of daily living vs placebo or salmeterol

•   The incidence of total lower respiratory tract adverse events (exacerbations)
    was different for salmeterol vs ipratropium, but both lead to fewer
    exacerbations vs placebo
Long-Acting Anticholinergic - Tiotropium
   Change in FEV1: Six Month Study

                                                                Tiotropium (n = 202)
                                          Day 169               Placebo (n = 179)

                  1.35

                  1.30

                  1.25

                  1.20
       FEV1 (L)



                  1.15

                  1.10

                  1.05

                  1.00

                  0.95
                         -1   0   1   2    3   4    5   6   7   8   9 10 11 12

                                  Time after administration (h)

     P < 0.001 for tiotropium vs placebo

   (DonohueJF, Chest 2002;122:47-55 )
Change in FEV1: Tiotropium vs Salmeterol vs Placebo


                                                                      Tiotropium (n = 202)
                                                Day 169               Salmeterol (n = 203)
                                                                      Placebo (n = 179)
                        1.35

                        1.30

                        1.25

                        1.20
             FEV1 (L)



                        1.15

                        1.10

                        1.05

                        1.00

                        0.95
                               -1   0   1   2    3   4    5   6   7   8   9 10 11 12

                                        Time after administration (h)

           P < 0.001 for tiotropium vs placebo
           P < 0.05 for tiotropium vs salmeterol
         (DonohueJF, Chest 2002;122:47-55 )
Change in FEV1: Tiotropium vs Salmeterol vs Placebo


                                                Day 1                 Tiotropium (n = 202)
                                                Day 169               Salmeterol (n = 203)
                                                                      Placebo (n = 179)
                        1.35

                        1.30

                        1.25

                        1.20
             FEV1 (L)



                        1.15

                        1.10

                        1.05

                        1.00

                        0.95
                               -1   0   1   2    3   4    5   6   7   8   9 10 11 12

                                        Time after administration (h)

           P < 0.001 for tiotropium vs placebo on all test days post-treatment
           P < 0.05 for tiotropium vs salmeterol on all test days except day 1
         (DonohueJF, Chest 2002;122:47-55 )
                     Binding and Dissociation

Human Muscarinic Receptors in CHO Cells

                                   M1        M2          M3
                                     Apparent KD (nM)
   Ipratropium                     0.43      0.54         0.69
   Tiotropium                      0.27      0.12         0.33


                                Dissociation Half-Life (hours)
   [3H]-Ipratropium                0.11      0.035        0.26
   [3H]-Tiotropium                 14.6      3.6          34.7


KD = dissociation constant                           Disse B et al. Life Sci 1993
                 Combination Therapy in COPD

                        CHRONIC
                       BRONCHITIS                                      EMPHYSEMA




                   AIRFLOW
                 OBSTRUCTION




                                                              ASTHMA


American Thoracic Society. Am J Respir Crit Care Med. 1995.
Bronchodilating Effects of Combined
Therapy With Clinical Dosages of
Ipratropium Bromide and Salbutamol for
Stable COPD:
Comparison With Ipratropium Bromide Alone

Akihiko Ikeda, MD, Koicht Nishimura
IPRATROPIUM BROMIDE AND SALBUTAMOL


                  50       80 mcg ipratropium + 400 mcg salbutamol
                           40 mcg ipratropium + 200 mcg salbutamol
FEV1 (% change)




                  40       80 mcg ipratropium
                           40 mcg ipratropium
                  30       Placebo

                  20

                  10

                  0
                       0      1        2       3       4      5           6         7      8
                                           Time After Test Dose (h)

                                                    Ikeda A, et al. Chest. 1996;109:294.
    Ipratropium and Albuterol per MDI
is More Effective than Either Agent Alone
     COMBINATION METERED DOSE INHALER
           (Ipratropium Bromide plus Albuterol Sulfate)



•   Effective bronchodilation via two distinct mechanisms.

•   Useful in the subset of patients who require both classes of agents
    to achieve maximal bronchodilation without potentiation of side
    effects over either single component alone.

•   Useful in noncompliant (non-adherent) patients- can improve
    adherence and patient satisfaction- by decreasing their time, effort,
    and the number of puffs required to administer two efficacious
    drugs.

•   Cost effective if restricted to these subsets of patients, and if the
    combination inhaler is properly priced.
          COMBINATION THERAPY IN COPD



•   Combination of ipratropium and long-acting beta-agonists have
    been shown to lead to significantly greater bronchodilation than
    that observed in response to either agent alone

     – Ipratropium + Salmeterol (Van Noord, Eur Resp J 2000;15:878-885)
     – Ipratropium + Formoterol (D’Urzo, Chest 2001;119:1347-1356)

•   A new generation anticholinergic agent, tiotropium bromide, which
    is more selective, more potent, and has a longer duration of action
    compared to ipratropium bromide is currently in development
    (Litner, Am J Respir Crit Care Med 2000;161:1136-1142)
Combination Therapy with an Anticholinergic
    and a Long-Acting Beta-2 Agonist

                   12.5                                                  Salmeterol 50 µg
                                                                         + ipratropium 40 µg
                    10                                                   Salmeterol 50 µg
 FEV1 (% Pred.)




                                                                         Placebo
                    7.5
                     5
                    2.5
                     0
                   -2.5
                     -5
                          0   0.5   1   2   3   4   5   6   7   8   9   10 11 12
                                                Time (hours)

    van Noord JA et al. Eur Respir J 2000;15:878-885
    OBJECTIVES FOR INTERVENTIONS
IN THE CHRONIC MANAGEMENT OF COPD


 •   Improvement in Lung Function
 •   Relieve Symptoms
 •   Decrease Exacerbations
 •   Decrease Hospitalizations
 •   Improve Quality of Life (Healthcare Status)
 •   Decelerate Decline in Lung Function
 •   Increase Life Expectancy
 •   Achieve Objectives in a Cost-Effective Manner
  COPD EXACERBATION - DEFINITION




Acute Worsening of Respiratory Symptoms (72hr)
  •   Increased Dyspnea

  •   Increased Quantity of Sputum

  •   Increased Purulence of Sputum




                                      Anthonisen NR 1987 Ann Int Med 106:196-204
                          FREQUENCY OF EXACERBATIONS



                     20



   % of Patients
With Exacerbations
                     10




                      0

                                Albuterol         Ipratropium   Ipratropium +
                                                                  Albuterol

    Friedman M, et al. Chest. 1999;115:635-641.
        COST OF HOSPITALIZATION FOR EXACERBATION




                                                                      Acquisition cost of primary
Albuterol                                                             pulmonary drug

                                                                      Acquisition cost of drugs
                                                                      added during exacerbations
Ipratropium
                                                                      Hospitalization cost



Ipratropium
+ Albuterol

               0       50     100     150     200   250   300   350      400     450     500




Friedman M, et al. Chest. 1999;115:635-641.
    PHARMACOLOGIC ARMAMENTARIUM

•   Anticholinergics (Parasympatholytic)
     •   Short-acting inhaled (Ipratropium)
     •   Long-acting (Tiotropium)

•   Beta Agonists (Sympathomimetic)
     •   Short-acting inhaled (numerous available)
     •   Long-acting inhaled (Salmeterol, Fomoterol)

•   Methylxanthines (Sympathomimetic)

•   Anti-Inflammatory
     •   Oral Steroids
     •   Inhaled Steroids
     •   Other anti-inflammatory agents (data pending)
Relationship Between Plasma Theophylline
    Concentrations and Clinical Effects

  Concentration                     Toxicity
                    Efficacy
     mg/liter

       5


                }
                     Minimal
      10                       Gastrointestinal Upset
                     Optimal       Nervousness
      20

      40                           Arrhythmias
                                   Convulsions
      60
                                         Liver
                                        Disease
       Age
                                                   Heart
                                                  Disease

Formulation   Theophylline Metabolism

                                                  Infection
  Smoking
                                        Severity
                                        of Illness
    PHARMACOLOGIC ARMAMENTARIUM

•   Anticholinergics (Parasympatholytic)
     •   Short-acting inhaled (Ipratropium)
     •   Long-acting (Tiotropium)

•   Beta Agonists (Sympathomimetic)
     •   Short-acting inhaled (numerous available)
     •   Long-acting inhaled (Salmeterol, Fomoterol)

•   Methylxanthines (Sympathomimetic)

•   Anti-Inflammatory
     •   Oral Steroids
     •   Inhaled Steroids
     •   Other anti-inflammatory agents (data pending)
LUNG INFLAMMATION IN ASTHMA IS DIFFERENT THAN
        THE LUNG INFLAMMATION IN COPD



•   The inflammation of asthma is responsive to steroids
    – Mast cells, eosinophils, TH2-like lymphocytes (CD4)
    – IL-4, IL-5, IL-13, ECP, LTC4

•   The chronic inflammation in COPD is not responsive
    to steroids
    – Macrophages, Neutrophils, T-Lymphocytes (CD8)
    – LTB4, TNF, IL-8, Chemokines
                 GOLD Guidelines
       (GOLD Guidelines Am J Respir Crit Care Med 2001;163:1256-1276)




•   Trial of inhaled corticosteroids (6 wks – 3 mo) given
    only if patient with moderate to severe COPD
    (defined by spirometry) continues with significant
    symptoms and frequent exacerbations (3 - 4 per yr)
    despite maximal bronchodilation.

•   If symptoms or the frequency of exacerbations are
    not improved, steroids should be discontinued.
        INHALED CORTICOSTEROIDS IN COPD


•   Copenhagen City Heart Study (Lancet 1999;353:1819-23)
    •   Mild-Moderate COPD (n=290)
    •   Budesonide 1200-800 micrograms/day
    •   No difference vs placebo in rate of decline in FEV1 over 3 years


•   EUROSCOP Trial (N Engl J Med 1999;340:1948-53)
    •   Mild COPD (n=1277)
    •   Budesonide 800 micrograms/day
    •   No difference vs placebo in rate of decline in FEV1 over 3 years
    •   Increase of 30-40ml FEV1 in treatment group early on which was
        sustained throughout the study
        INHALED CORTICOSTEROIDS IN COPD

•   Lung Health Study (N Engl J Med 2000;343:1902-1909)
    •   Moderate COPD, FEV1 of 2L (n=1116)
    •   Triamcinolone 1200 micrograms/day
    •   No difference vs placebo in rate of decline in FEV1 over 3.5 years
    •   Modest improvement in dyspnea and onset of severe symptoms
    •   Increased risk of osteoporosis

•   ISOLDE Trial (BMJ 2000;320:1297-303)
    •   Moderate to severe COPD , FEV1 of 1.5L (n=751)
    •   Fluticasone 1000 micrograms/day
    •   No difference vs placebo in rate of decline in FEV1 over 3 years
    •   Increase of 100ml FEV1 in treatment group early on which was
        sustained throughout the study
    •   Exacerbations decreased by 25% in treatment group
SYSTEMIC CORTICOSTEROIDS SHOULD BE USED DURING
         ACUTE EXACERBATIONS OF COPD



   Two studies have shown efficacy for the use of
   systemic steroids during acute COPD exacerbations

           • Niewoehner DE et al, NEJM 340:1941, 1999
           • Davies L et al, Lancet 354:456, 1999

           Once daily Solumedrol (60 mg iv) or
           Once daily Prednisone (30 - 40mg po)

                Taper off in 5-7 days
                    CORTICOSTEROIDS DURING
                  ACUTE EXACERBATIONS OF COPD




Niewoehner et al NEJM 1999;340:1941
    OBJECTIVES FOR INTERVENTIONS
IN THE CHRONIC MANAGEMENT OF COPD


 •   Improvement in Lung Function
 •   Relieve Symptoms
 •   Decrease Exacerbations
 •   Decrease Hospitalizations
 •   Improve Quality of Life (Healthcare Status)
 •   Decelerate Decline in Lung Function
 •   Increase Life Expectancy
 •   Achieve Objectives in a Cost-Effective Manner
MONTHLY ACQUISITION COSTS FOR COPD DRUGS (AWP)
                    (REDBOOK, 2002 Edition)


                                              No. MDIs/Month
    Albuterol                                         1.2

  Ipratropium
                                                      1.2

  Albuterol +
 Ipratropium                                     1.2 + 1.2

  Albuterol +
 Ipratropium                                          1.2
 (single MDI)
                                                      1.0
  Formoterol


 Salmeterol                                           1.0

Salmeterol +
   Albuterol                                     1.0 + 1.2



                AWP/month (Dollars)
MONTHLY ACQUISITION COSTS FOR COPD DRUGS (AWP)
                             (REDBOOK, 2002 Edition)




            Albuterol                                  No. MDIs/Month
                                                             1.2
          Ipratropium
                                                             1.2
Albuterol +Ipratropium
     (Single MDI)                                            1.2

 Formoterol + Albuterol                                      1.0 + 1.2

Salmeterol + Albuterol                                       1.0 + 1.2




   Beclomethasone                                            1.2

     Fluticasone 110                                         1.0

     Fluticasone 220                                         1.0

        Flunisolide                                          1.2

        Budesonide                                           0.6
     Fluticasone 500                                         1.0
     + Salmeterol 50
       Combination



                          AWP/month (Dollars)
    OBJECTIVES FOR INTERVENTIONS
IN THE CHRONIC MANAGEMENT OF COPD


 •   Improvement in Lung Function
 •   Relieve Symptoms
 •   Decrease Exacerbations
 •   Decrease Hospitalizations
 •   Improve Quality of Life (Healthcare Status)
 •   Decelerate Decline in Lung Function
 •   Increase Life Expectancy
 •   Achieve Objectives in a Cost-Effective Manner
MODALITIES IMPROVING SURVIVAL IN COPD




     • Successful Smoke Cessation
         (Behavioral Modification Required)

     • Oxygen Therapy
         (Minimum of 15-18 hr qd)
NON-PHARMACOLOGIC ARMAMENTARIUM

 •   Successful Smoke Cessation
 •   Pulmonary Rehabilitation (formal/informal)
     •   Overall Education
     •   Exercise Program (home program)
     •   Nutrition
     •   Vaccination
     •   Pulmonary Hygiene (?mucolytic agents)

 •   Antibiotics
 •   Transplantation (Single Lung)
 •   Oxygen, Noninvasive Ventilation
 •   Experimental (LVRS, Anti-oxidants/Vitamins)
THE NATIONAL COPD AWARENESS PANEL (NCAP)
      Journal of Respiratory Diseases 21:S1-21, Sept 2000
      Journal of Respiratory Diseases 23:S1-52, Sept 2002



      •   Carol Boland (Nurse Practitioner)
      •   Dick D. Briggs (Pulmonary)
      •   Dennis E. Doherty (Pulmonary)
      •   Harold Hedges III (Family Medicine)
      •   Louis Kuritzky (Family Medicine)
      •   Ron Levine (Internal Medicine)
      •   Kenneth Pellegrino (Family Medicine)
      •   Alan Radin (Internal Medicine)
      •   Steven A. Sahn (Pulmonary)
         COPD Management in Primary Care
      NCAP- Journal of Respiratory Diseases 23:S1-52, Sept 2002
    GOLD Guidelines Am J Respir Crit Care Med 2001;163:1256-1276



•   Sustained Smoking Cessation
•   First-line Therapy is to Maximize Bronchodilation
    •   Anticholinergics (short- or long-acting)
    •   Beta-2 Agonists (short- or long-acting)
    •   Methylxanthines

•   After Maximal Bronchodilation with multiple agents in
    patients with severe COPD and frequent exacerbations
    •   A trial of Inhaled Corticosteroids can be considered
         – 6 week to 3 month trial
         – Monitor Spirometry and Symptoms
         – Discontinue if no improvement in that time period
              VACCINNATION IN COPD


•   Pneumococcal
    •   In all COPD Patients
    •   Patients > 65 vaccinated more than 5 years previously should
        be revaccinated, if unsure - revaccinate
    •   Evidence for efficacy is inconclusive (some studies show a 65-
        85% efficacy amongst high-risk populations)

•   Influenza
    •   Administer annually unless there is a history of severe
        anaphylaxis to egg protein
    •   30-80% effective in preventing illness, complications, and death
        in high-risk populations
    •   Can be administered concurrently with pneumococcal vaccine
        if administered at different sites
    For more information on COPD

National Lung Health Education Program

            www.nlhep.org


         U.S. COPD Coalition

          www.uscopd.com
�   Harold Hedges III (Family Medicine)
      •   Louis Kuritzky (Family Medicine)
      •   Ron Levine (Internal Medicine)
      •   Kenneth Pellegrino (Family Medicine)
      •   Alan Radin (Internal Medicine)
      •   Steven A. Sahn (Pulmonary)
         COPD Management in Primary Care
      NCAP- Journal of Respiratory Diseases 23:S1-52, Sept 2002
    GOLD Guidelines Am J Respir Crit Care Med 2001;163:1256-1276



•   Sustained Smoking Cessation
•   First-line Therapy is to Maximize Bronchodilation
    •   Anticholinergics (short- or long-acting)
    •   Beta-2 Agonists (short- or long-acting)
    •   Methylxanthines

•   After Maximal Bronchodilation with multiple agents in
    patients with severe COPD and frequent exacerbations
    •   A trial of Inhaled Corticosteroids can be considered
         – 6 week to 3 month trial
         – Monitor Spirometry and Symptoms
         – Discontinue if no improvement in that time period
              VACCINNATION IN COPD


•   Pneumococcal
    •   In all COPD Patients
    •   Patients > 65 vaccinated more than 5 years previously should
        be revaccinated, if unsure - revaccinate
    •   Evidence for efficacy is inconclusive (some studies show a 65-
        85% efficacy amongst high-risk populations)

•   Influenza
    •   Administer annually unless there is a history of severe
        anaphylaxis to egg protein
    •   30-80% effective in preventing illness, complications, and death
        in high-risk populations
    •   Can be administered concurrently with pneumococcal vaccine
        if administered at different sites
    For more information on COPD

National Lung Health Education Program

           www.nlhep.org


         U.S. COPD Coalition

          www.uscopd.com