MRCGP Exam Update - Managing COPD

Louise Newson, a GP in the West Midlands and author of 'HotTopics for MCRGP and General Practitioners' PasTest 2006

Current situation - COPD is the fourth leading cause of death worldwide and causes more than 30,000 deaths a year in the UK. It is both under-diagnosed and under-recognised.

- At least 25 per cent of long-term smokers will develop COPD (Thorax 2006; 61: 935-9).

WHAT IS THE EVIDENCE?

- One study has demonstrated the merits of tiotropium; those COPD patients receiving tiotropium over a one-year period had far fewer exacerbations - both frequency and duration - than those receiving placebo. They also had improved trough FEV1 levels (Eur Respir J 2006; 27: 547-55).

- A study has shown impressive results for a combination of tiotropium and the long-acting beta-agonist formoterol. Those patients who received the combination had less airflow reduction and less need for rescue treatment with salbutamol (Chest 2006; 129: 509-17).

- There is found to be a high prevalence of anxiety and depression among patients with chronic breathing disorders (Chest 2005; 127: 1,205-11). According to this study, 65 per cent screened positive for depression and anxiety, 10 per cent for anxiety only and 5 per cent for depression only.

- Combination treatment reduces the frequency of COPD exacerbations compared with monotherapy, according to a new study (Am J Respir Crit Care Med 2007; 175:144-9). There was a 35 per cent reduction in annual rate of exacerbation in the combination group compared with those using salmeterol alone.

- The combination of inhaled salmeterol and fluticasone has been shown to slightly reduce the risk of exacerbation compared with placebo alone (New Engl J Med 2007; 356: 775-89).

IMPLICATIONS FOR PRACTICE

- Steroids reduce exacerbations in patients with a FEV1 of less than 50 per cent predicted and a history of two or more exacerbations in the preceding year.

- Inhaled steroids have been a controversial therapy in COPD for over a decade. A meta-analysis has demonstrated that inhaled corticosteroids reduce mortality by about 25 per cent over a two-year period in patients with COPD when compared with placebo (Thorax 2005; 60: 992-7).

- Screening for COPD in smokers over the age of 40 years could detect up to 20 per cent of undiagnosed cases, according to one study (Prim Care Respir J 2007; 16: 41-8).

AVAILABLE GUIDELINES

- Global Initiative for Chronic Obstructive Lung Disease (GOLD), and the American Thoracic Society and the European Respiratory Society (ATS/ERS) and NICE.

- NICE guidelines are evidence-based and serve to clarify, standardise and improve the treatment of patients with COPD.

USEFUL WEBSITES

www.brit-thoracic.org.uk - British Thoracic Society

www.nice.org.uk - NICE

www.goldcopd.com - GOLD

KEY POINTS
- COPD is still underdiagnosed.
- Many patients are also depressed and anxious.
- Tiotropium is increasingly used.
- NICE guidelines are useful.

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