MRCGP Exam Update - COPD management

Current situation

- COPD is the fourth leading cause of death worldwide and causes over 30,000 deaths a year in the UK (Lancet 2004; 364: 564).

- It is both underdiagnosed and under-recognised.

- There are now more treatment options for patients with COPD.

- The DoH has announced plans to publish an NSF for COPD in 2008.

What is the evidence?

- The antimuscarinic bronchodilator, tiotropium, is increasingly being prescribed to patients with COPD. One study has shown that fewer patients have exacerbations with tiotropium compared with placebo. Its use also led to lower hospitalisation rates (Ann Intern Med 2005; 143: 317).

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

- One study has shown the merits of the combination of tiotropium and the long-acting beta-agonist formoterol. The results were very good - those patients who received the combination had less airflow reduction and demonstrated less need for rescue treatment with salbutamol (Chest 2006; 129: 509) .

- There appears to be a high prevalence of anxiety and depression among patients with chronic breathing disorders (Chest 2005; 127: 1205).

According to this study, 65 per cent of patients screened positive for depression and anxiety, 10 per cent for anxiety only and 5 per cent for depression only.

Implications for practice

- Steroids reduce exacerbations in patients with a FEV1 of less than 50 per cent of 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).

Available guidelines

- Although there are numerous guidelines for diagnosis, management, and prevention of COPD, they all lag behind developments in clinical research (BMJ 2005; 330: 640).

- Guidelines have been published by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and regional bodies such as 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 COPD.

USEFUL WEBSITES

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

www.nice.org.uk - NICE

www.goldcopd.com - World Health Organisation Global Initiative for Chronic Obstructive Lung Disease

- Dr Louise Newson is a GP in the West Midlands and author of 'Hot Topics for MRCGP and General Practitioners', Pas Test 2006.

KEY POINTS
- COPD is still underdiagnosed.
- Many patients are also depressed and anxious.
- Use of tiotropium is increasing.
- NICE guidelines are useful.
- NSF for COPD due in 2008.

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