Chronic obstructive pulmonary disease in over 16s: diagnosis and management

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) frequently occur together and their coexistence is associated with worse outcomes than either condition alone. Pathophysiological links between COPD and CVD include lung hyperinflation, systemic inflammation and COPD exacerbations. COPD treatments may produce beneficial cardiovascular (CV) effects, such as long-acting bronchodilators, which are associated with improvements in arterial stiffness, pulmonary vasoconstriction, and cardiac function. However, data are limited regarding whether these translate into benefits in CV outcomes. Some studies have suggested that treatment with long-acting β2-agonists and long-acting muscarinic antagonists leads to an increase in the risk of CV events, particularly at treatment initiation, although the safety profile of these agents with prolonged use appears reassuring. Some CV medications may have a beneficial impact on COPD outcomes, but there have been concerns about β-blocker use leading to bronchospasm in COPD, which may result in patients not receiving guideline-recommended treatment. However, there are few data suggesting harm with these agents and patients should not be denied β-blockers if required. Clearer recommendations are necessary regarding the identification and management of comorbid CVD in patients with COPD in order to facilitate early intervention and appropriate treatment.

https://err.ersjournals.com/content/errev/27/149/180057.full.pdf

Cardiovascular disease and COPD: dangerous liaisons?

Introduction: Chronic obstructive pulmonary disease (COPD) is characterised by persistent respiratory symptoms and chronic airflow limitation, and is associated with exacerbations and comorbidities. Advances in the management of COPD are updated quarterly in the national COPD guidelines, the COPD-X plan, published by Lung Foundation Australia in conjunction with the Thoracic Society of Australia and New Zealand and available at http://copdx.org.au. Main recommendations: ∙ Spirometry detects persistent airflow limitation (post-bronchodilator FEV/FVC < 0.7) and must be used to confirm the diagnosis. ∙ Non-pharmacological and pharmacological therapies should be considered as they optimise function (ie, improve symptoms and quality of life) and prevent deterioration (ie, prevent exacerbations and reduce decline). ∙ Pulmonary rehabilitation and regular exercise are highly beneficial and should be provided to all symptomatic COPD patients. ∙ Short- and long-acting inhaled bronchodilators and, in more severe disease, anti-inflammatory agents (inhaled cortico-steroids) should be considered in a stepwise approach. ∙ Given the wide range of inhaler devices available, inhaler technique and adherence should be checked regularly. ∙ Smoking cessation is essential, and influenza and pneumococcal vaccinations reduce the risk of exacerbations. ∙ A plan of care should be developed with the multidisciplinary team. COPD action plans reduce hospitalisations and are recommended as part of COPD self-management. ∙ Exacerbations should be managed promptly with bronchodilators, corticosteroids and antibiotics as appropriate to prevent hospital admission and delay COPD progression. ∙ Comorbidities of COPD require identification and appropriate management. ∙ Supportive, palliative and end-of-life care are beneficial for patients with advanced disease. ∙ Education of patients, carers and clinicians, and a strong partnership between primary and tertiary care, facilitate evidence-based management of COPD. Changes in management as result of the guideline: Spirometry remains the gold standard for diagnosing airflow obstruction and COPD. Non-pharmacological and pharmacological treatment should be used in a stepwise fashion to control symptoms and reduce exacerbation risk.

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COPD-X Australian and New Zealand guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2017 update.

Background Observational studies suggest that beta-blockers may reduce the risk of exacerbations and death in patients with moderate or severe chronic obstructive pulmonary disease (COPD),...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1908142?articleTools=true

Metoprolol for the Prevention of Acute Exacerbations of COPD.

Understanding the impact of chronic obstructive pulmonary disease exacerbations on patient health and quality of life

COPD often coexists with chronic conditions that may influence disease prognosis. We investigated associations between chronic (co)morbidities and exacerbations in primary care COPD patients. Retrospective cohort study based on 2012–2013 electronic health records from 179 Dutch general practices. Comorbidities from patients with physician-diagnosed COPD were categorized according to International Classification of Primary Care (ICPC) codes. Chi-squared tests, uni- and multivariable logistic, and Cox regression analyses were used to study associations with exacerbations, defined as oral corticosteroid prescriptions. Fourteen thousand six hundred three patients with COPD could be studied (mean age 67 (SD 12) years, 53% male) for two years. At baseline 12,826 (88%) suffered from ≥1 comorbidities, 3263 (22%) from ≥5. The most prevalent comorbidities were hypertension (35%), coronary heart disease (19%), and osteoarthritis (18%). Several comorbidities showed statistically significant associations with frequent (i.e., ≥2/year) exacerbations: heart failure (odds ratio [OR], 95% confidence interval: 1.72; 1.38–2.14), blindness & low vision (OR 1.46; 1.21–1.75), pulmonary cancer (OR 1.85; 1.28–2.67), depression 1.48; 1.14–1.91), prostate disorders (OR 1.50; 1.13–1.98), asthma (OR 1.36; 1.11–1.70), osteoporosis (OR 1.41; 1.11–1.80), diabetes (OR 0.80; 0.66–0.97), dyspepsia (OR 1.25; 1.03–1.50), and peripheral vascular disease (OR 1.20; 1.00–1.45). From all comorbidity categories, having another chronic respiratory disease beside COPD showed the highest risk for developing a new exacerbation (Cox hazard ratio 1.26; 1.17–1.36). Chronic comorbidities are highly prevalent in primary care COPD patients. Several chronic comorbidities were associated with having frequent exacerbations and increased exacerbation risk.

/pdf/associations-between-chronic-comorbidity-and-exacerbation-2t6vb7jb10.pdf

Associations between chronic comorbidity and exacerbation risk in primary care patients with COPD

Inleiding Voor de incidentie van de ziekte van Lyme zijn tot nog toe slechts ruwe schattingen beschikbaar. Wij onderzochten de incidentie van Lyme op basis van elektronische dossiers uit Nederlandse huisartsenpraktijken over de periode 2009-2014. Verder analyseerden we de kenmerken van de betreffende patienten en keken we in hoeverre de huisartsen de CBO-richtlijn uit 2013 volgden. Methode In het eerstelijns registratienetwerk FaMe-net selecteerden we dossiers uit de jaren 2009-2014 die specifieke ICPC- en ICD-codes bevatten. Resultaten We identificeerden 212 patienten met Lyme. De gemiddelde incidentie was 117 per 100.0000 patienten per jaar. Er was geen significante trend in de incidentie gedurende de onderzoeksperiode. Voor 95% van de patienten was huiduitslag of een insectensteek de reden om naar de huisarts te gaan. Bijna iedereen (99%) kreeg een antibioticum voorgeschreven en voor 25% werd bloedonderzoek aangevraagd. Bij 46% volgde de huisarts de CBO-richtlijn niet volledig, meestal door een te lange antibioticakuur voor te schrijven of ten onrechte bloedonderzoek aan te vragen. Conclusie Een huisarts met een normpraktijk van 2250 patienten ziet jaarlijks gemiddeld drie patienten met de ziekte van Lyme. Naast verwachtingen, wensen of angsten van de patient kan onbekendheid met de richtlijn een reden zijn om de richtlijn niet precies te volgen.

Ziekte van Lyme in de Nederlandse huisartsenpraktijk

BACKGROUND: Little is known about the presentation and management of Lyme disease in general practice. OBJECTIVE: To investigate the incidence of Lyme disease over a 6-year period, and its presentation and management in Dutch general practice. METHODS: Observational study using routine data from a practice-based research network in the Netherlands with 7 practices, 24 GPs and 30000 registered patients. From 2009 to 2014, we calculated the incidence of patients presenting with Lyme disease in general practice. We analysed patient characteristics and symptoms that patients presented with at first visit. Furthermore, we analysed General Practitioners' (GPs') diagnostic and therapeutic strategies, and adherence to the national guideline. RESULTS: Over a 6-year period, we found 212 episodes with clinical- or laboratory-based diagnosed Lyme disease, resulting in a mean incidence of 117 cases per 100000 patients per year. We did not identify a significant linear trend over time. The most frequently reported symptoms at first visit were rash (77%) and/or insect bite (58%). In 25% of patients, GPs performed a serological test, in 99% an antibiotic was prescribed and 11% were referred to a medical specialist. Frequently (in 46% of patients), the GP did not adhere to the guideline completely. CONCLUSION: This study shows that there is no linear trend in the incidence of Lyme disease over a 6-year period and that most patients present to GPs with unspecific symptoms like rash or insect bites. We show that GPs frequently (in 46% of patients) do not fully adhere to recommendations stated in the national guideline.

Waling Tiersma

Papers

Associations between chronic comorbidity and exacerbation risk in primary care patients with COPD

Ziekte van Lyme in de Nederlandse huisartsenpraktijk

Incidence, presentation and management of Lyme disease in Dutch general practice.