Challenges and opportunities

in COPD in 2020Prof Peter Wark

Centre for Healthy Lungs HMRI, University

of Newcastle Department of Respiratory

and Sleep Medicine John Hunter Hospital

NHMRC Centre of Excellence in Severe

Asthma

Outline The global burden of chronic lung disease

Chronic lung disease and Papua New Guinea?

Chronic Obstructive Pulmonary Disease (COPD)

and GOLD 2019

Asthma and GINA 2019

HMRI is a partnership between the University of Newcastle, Hunter New England Local Health District and the Community.

The rise of chronic non-communicable

disease Kitur et al BMC Public Health 2019

Death and disability in PNG

Lower lung function is associated with

worse mortality Anderson et al Int J Epidemiol 1988

15 year mortality, 1970-71 to

1984-85

Lufa (Highlands)

- 2026

Karkar island

- 1734

Mortality associated- FEV1

- FVC

- FEV1/FVC

Chronic Obstructive Pulmonary Disease

COPD is a common, preventable, treatable

disease that is characterized by persistent

respiratory symptoms and airflow limitation

COPD the size of the problem

World wide

– is the 4th leading cause of death

– 12 leading cause of disability in the world (est

to be 5th by 2020)

Australia

– Afflicts 665 000 (3.5%)

– 4th leading cause of death in Australia (2001)

Risk Factors for COPDNutrition

Infections

Socio-economic

status

Aging Populations

Note: This is a simplified diagram of FEV1 progression over time. In reality, there is tremendous heterogeneity in the rate of decline in FEV1

owing to the complex interactions of genes with environmental exposures and risk factors over an individual’s lifetime

[adapted from Lange et al. NEJM 2015;373:111-22].

© 2020 Global Initiative for Chronic Obstructive Lung Disease

TB as a risk factor for COPDByrne et al Int J Infect Dis 2015

SYMPTOMS

Cough

Sputum

Shortness of breath

EXPOSURE TO RISKFACTORS

Tobacco

Occupation

Indoor air pollution

SPIROMETRY

Diagnosis of COPD

From the Global Strategy for the Diagnosis, Management, and Prevention of

Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive

Lung Disease (GOLD) 2008. Available from: http://www.goldcopd.org.

Outdoor air pollution

Assessment of COPD

1. Assess symptoms

2. Assess degree of airflow limitation using

spirometry

3. Assess risk of exacerbations and future risk

4. Assess comorbidities

FEV1 FVC FEV1 / FVC

Normal 4.150 5.200 80%

COPD 2.350 3.900 60%

5

4

3

2

1

1 2 3 4 5 6

Lit

ers COPD

Normal

FEV1

Seconds

FEV1

FVC

FVC

From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary

Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2008. Available from:

http://www.goldcopd.org.

Spirometry for COPD Diagnosis and

Classification of Severity

Assess severity of airflow obstruction

Assess symptoms; COPD assessment

test, the CAT

© 2020 Global Initiative for Chronic Obstructive Lung Disease

Assess risk of exacerbations

2 or more exacerbations in the last year (Hurst

et al NEJM 2010)

FEV1 <60% predicted (Donaldson et al Thorax 2006)

Chronic bronchitis (Burgel et al Chest 2009)

Greater impairment in exercise tolerance

GOLD severity

Angina

Cataracts

Respiratory Infection

Myocardial Infarction

Fractures

Osteoporosis

Glaucoma

Skin Bruises

Soriano et al. Chest. 2005;128:2099-2107.

RR in COPD versus non-COPD

Rate

per

10,0

00

4320 1

0

100

200

300

400

Pneumonia

Assess co-morbidities

Management of COPD

Management of COPD Improve symptoms

- Reduce airflow obstruction

- Enhance exercise capacity

Reduce exacerbation risk and loss of lung

function

- Smoking cessation

- Vaccination

- Long acting anticholinergics

- Inhaled corticosteroids

COPD Management

COPDX LFA

Combined LAMA + LABA

Bateman et al Eur Resp J 2013

Anthonisen et al. Am J Respir Crit Care Med. 2002;166:675-679. Reproduced with

permission from American Thoracic Society. Copyright © 2002

0Year

FE

V1

(Lite

rs)

1 2 3 4 5 6 7 8 9 10 11

2.9

2.8

2.7

2.6

2.5

2.4

2.3

2.2

2.1

2.0

Sustained Quitters

Intermittent

Quitters

Continuous Smokers

Benefit of Smoking Cessation: Lung Health Study 11-

year Results

Tiotropium and LAMAs: reduce exacerbations

OR=0.75

NNT 14 (11-22)

1. Barr et al The Cochrane Database of Systematic Reviews 2006 Issue 4

LABA/LAMA vs ICS/LABA, The “Flame

study” Wedzicha NEJM 2016

IMPACT: Effect on moderate/severe exacerbations with

FF/UMEC/VI vs FF/VI or UMEC/VI (ITT population)

Note: The n reflects the number of patients included in each analysis from the ITT population. Patients were excluded if they had predefined data missing; this varied according to

the analysis. The ITT population comprised: 4151 patients treated with TRELEGY, 4134 patients treated with BREOand 2070 patients treated with ANORO.

UMEC/VIn = 2,069

Mo

de

rate

/se

ve

re e

xa

ce

rba

tio

ns

(an

nu

alr

ate

)

FF/UMEC/VIn = 4,145

FF/VIn = 4,133

0.91

1.071.21

2.0

1.8

1.6

1.4

1.2

1.0

0.8

0.6

0.4

0.2

0

(95% CI: 19, 30)

p < 0.001

Lipson DA, et al. N Engl J Med. 2018;378:1671–1680

(95% CI: 10, 20)

p < 0.001

15%

25%

FF/UMEC/VI: Fluticasone Furoate/Umeclidinium/Vilanterol 100/62.5/25mcgUMEC/VI: Umeclidinium/Vilanterol 62.5/25mcgFF/VI: Fluticasone Furoate/Vilanterol 100/25mcg

R

FF/UMEC/VI 100/62.5/25 µg OD* (n=4151)

UMEC/VI 62.5/25 µg OD* (n=2070)

FF/VI 100/25 µg OD* (n=4134) Current

COPD meds

2 weeks

Follow-up

1 week

52 weeks

Double-blind

COPD Management

COPDX LFA

COPD treatment in the developing nations AitKhaled et al Bulletin Who 2001