Optimal treatment of COPD in a primary care setting

Development Group: Singh, Dickinson, Sapey & Small


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This management algorithm was developed by a multidisciplinary expert panel: Singh D et al with the support of a grant from AstraZeneca. See bottom of page for full disclaimer.

Diagnosis and definitions

  • Diagnosis of COPD:
    • risk factor (generally smoking)
    • exertional breathlessness, chronic cough, regular sputum production, frequent winter ‘bronchitis’, and/or wheeze
    • forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) ratio <0.7
    • (see GOLD COPD guideline or guideline summary)
  • Exacerbation—acute worsening of symptoms beyond the normal day-to-day variation:
    • refer to Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy or guidance on management of exacerbations
  • Frequent exacerbator—patient who has experienced ≥2 exacerbations requiring oral corticosteroids and/or antibiotics or one hospitalisation for COPD in the past year

Non-pharmacological management

  • Assess inhaler use and technique at each stage prior to escalating treatment and opportunistically at every consultation:
    • monitor inhaler use using repeat prescription history
  • Discuss smoking cessation at each stage prior to escalating treatment
  • Encourage patients to identify triggers for exacerbations and encourage self-management based on early recognition of, and actions taken for, exacerbations
  • Reinforce lifestyle advice on diet and exercise in all patients at every opportunity
  • Offer pulmonary rehabilitation to all patients depending on local pathways and availability
  • Long-term oxygen therapy
  • Multidisciplinary support and treatment for patients with severe disease

Pharmacological management

  • Check summary of product characteristics before prescribing to rule out contraindications and precautions
  • Choose short- and long-acting β-agonist (SABA and LABA), short- and long-acting muscarinic agonist (SAMA and LAMA), and inhaled corticosteroid (ICS) according to local formulary
  • LABA/LAMA combination inhalers are a new drug class that improves lung function, symptoms, and exacerbation rates
  • Ensure patients have maximal bronchodilation using LABA/LAMA before prescribing ICS. This practice will ensure ICS/LABA use only in patients who are frequent exacerbators despite optimised lung function
  • Review use of ICS in non-exacerbators:
    • consider stopping in patients with FEV1 >50% predicted
    • consider discussing use of ICS in patients with FEV1 30–50% predicted with COPD service
    • continue ICS in patients with FEV1 <30% predicted
  • Oral steroids are not recommended for routine use

Follow-up

  • Ask patients to return if symptoms do not improve or worsen
  • Review patients at least every 12 months and earlier if they experience an exacerbation

Referral

  • Refer patients who are still symptomatic on maximal bronchodilation, who are still exacerbating/admitted to hospital on triple therapy, or in whom there is diagnostic uncertainty to local COPD service for confirmation of diagnosis and evaluation of further management options, such as theophylline, mucolytics and antibiotics, which should not routinely be initiated in primary care
  • Consider early referral of patients with symptoms suggestive of bronchiectasis (e.g. excess sputum or evidence of recurring colonisation) and patients with hypoxaemia.

Useful resources

References

about this management algorithm...

sponsor -

This algorithm has been developed by MGP Ltd, the publishers of Guidelines, and the expert group was convened by them. AstraZeneca was able to recommend an expert to Chair the group and comment on the scope and title, with final decisions resting with the Chair. AstraZeneca had the opportunity to comment on the technical accuracy of this algorithm but the content is independent of and not influenced by AstraZeneca

group members -

Professor Dave Singh (Chair, professor of clinical pharmacology and respiratory medicine), Dr Mark Dickinson (head of prescribing and medicines optimisation), Dr Liz Sapey (respiratory consultant), Dr Iain Small (general practitioner and PCRS-UK executive member)

further information -

call MGP Ltd (01442 876100)

GL/ABF/0515/0442

May 2015

 


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