New Therapies for COPD 2013 Edward Omron MD, MPH, FCCP

Edward Omron MD, MPH, FCCPPulmonary, Critical Care, and

Internal Medicine18525 Sutter Blvd, Suite 180Morgan Hill, CA 950371408-778-0022deepbreath@docomron.comwww.docomron.com

Chronic, progressive shortness breath Symptoms

◦ Cough◦ Phlegm◦ Chest Pressure◦ Wheezing◦ Exercise limitation

Two irreversible lung diseases that frequently coexist together:◦ Chronic bronchitis: airways of the lung are

inflamed, swollen and narrowed resulting in “wheezing” HEAVY mucus or phlegm is coughed up Breeding ground for recurrent infections

◦ Emphysema: the scaffolding of the lung is destroyed resulting in multiple “holes”

Bronchitic Emphysematous

Third leading cause of death in America◦ 125,000 lives in 2007

Smoking is the primary risk factor for COPD

Female smokers are 13 times more likely to die from COPD than females who never smoked

13 million adults were estimated to have COPD in 2008

50 Billion in health care costs yearly

Tobacco Smoke!!!! Occupational Exposures

◦ Coal Miners◦ Smelters◦ Shipyards

Genetics is Very Important!

Pulmonary Physician Appropriate Symptoms Diagnostic Studies

◦ Chest X-Ray◦ Pulmonary Function Study◦ 6 minute walk test◦ Arterial Blood Gas◦ Alpha 1 antitrypsin deficiency

Congestive Heart Failure Asthma Bronchiectasis Interstitial Lung Disease

Patient Education◦ Early treatment for exacerbations◦ Appropriate treatment for symptoms◦ Reduce risk factors◦ How to treat an exacerbation ◦ Inhalers◦ Nebulizers◦ Pulmonary Rehabilitation

Bronchodilators◦ B Agonists◦ Anticholinergics◦ Xanthines

Pulmonary Specialist to determine which is best

Glucocorticoids (Steroids)◦ Oral prednisone for flair-up of disease◦ Intravenous usage in hospital◦ Inhaled usage for outpatient

Risks◦ Fractures◦ Diabetes◦ Infection

Vaccines◦ Influenza, pneumococcus

Antibiotics Flutter valve Supplemental Oxygen Mucolytics Pulmonary Rehab

Shortness of breath = inactivity Muscle Weakness = Fatigue Loss of independence = depression Isolation Weight Gain Immune system weakens

Builds Strength Less shortness of breath More independence Greater reserve to fight infection Less fatigue Weight control Quality of life

Under care of a health professional Physical Therapist guides training Stretches Aerobic Conditioning How to cough, breath, and train safely

Indacaterol (Arcapta Neohaler)◦ Once daily long acting (24 hours) bronchodilator

in COPD◦ Rapid onset with intense bronchodilation◦ Improvement in shortness of breath, exercise

performance, and quality of life.◦ Hopefully available later this year, excellent

safety profile

Phosphodiesterase inhibitors (similar to caffeine)

Decreases airway inflammation Not a bronchodilator Side effects: Headache, Nausea, Diarrhea Reduces COPD exacerbations Once daily oral dosing, cannot be used in

liver dysfunction

A genetic condition associated with early onset COPD and liver disease

Alpha 1-Antitrypsin is a enzyme that protects the lung from enzymes that break down lung tissue

About 1-3% of patients with COPD are predicted to have alpha1-antitrypsin deficiency.

Intravenous (IV) augmentation therapy with alpha1-antitrypsin benefits some patients

Identified in all populations All COPD patients are now screened for this

disorder

Inhaled long-term, once-daily maintenance treatment in patients with chronic obstructive pulmonary disease (COPD)

Combination of the inhaled corticosteroid (ICS), fluticasone furoate and the long-acting beta2 agonist (LABA), vilanterol

Will be available in the US during the third quarter of 2013

Should not be used as rescue therapy An increase in the incidence of pneumonia is

noted with this class of combination drugs

Lung Reduction Surgery◦ Improved exercise capacity, quality of life◦ Upper lobe emphysema best outcome◦ No survival advantage

Lung Transplantation◦ COPD, CF, IPF, Idiopathic Pulmonary

Hypertension◦ BODE Score 7-10◦ Median survival 6 years

Endobrobronchial Valves◦ Advanced emphysema◦ Modest improvement◦ Frequent COPD exacerbations and hemoptysis

Stem cells are derived from the bone marrow◦ Can regenerate normal lung tissue with

manipulation◦ Several studies in animal models show great

promise in COPD◦ Too early to comment

Vitamin D◦ Early enthusiasm ◦ Most recent study in severe COPD disappointing◦ No consensus

American Lung Association◦ http://www.lung.org/lung-disease/

http://www.onebreath.org/ NEJM 2003; 348:2059-2073 NEJM 2010; 363: 1233-1244 Am J Respir Crit Care Med 2013; 187:468-475 Am J Respir Crit Care Med 2013; 187: 228-

237 Am J Respir Crit Care Med 2011; 159-171

Edward M. Omron MD, MPH, FCCP

Pulmonary, Critical Care, and Internal Medicine

18525 Sutter Blvd, Suite 180 Morgan Hill, CA 95037 1-408-778-0022