英文ppt课件treatmenttargets in copd current and evolving management

Leonardo M. Fabbri Clinica di Malattie dellApparato Respiratorio Universit degli Studi di Modena e Reggio Emilia Azienda Ospedaliero-Universitaria - Policlinico di Modena Ridefinizione della BPCO e delle riacutizzazioni dei sintomi in pazienti con BPCO Modena 6-7/8-9 Settembre 2011 Corso di Aggiornamento su MALATTIE RESPIRATORIE COPD and chronic comorbidities Exacerbations in COPD Current and future treatment Treatment of co-morbidities of COPD Futuristic treatments TREATMENT TARGETS IN COPD: CURRENT AND EVOLVING MANAGEMENT OPTIONS 20%-24% (1 year) 2.5%-10% (5 days) 22%-32% (14 days) 13%-33% (14 days) Hospital mortality Hospital mortality Relapse (repeat ER visit) Treatment failure rate OUTCOME OF COPD EXACERBATIONS Seneff et al. JAMA. 1995; 274:1852-1857; Murata et al. Ann Emerg Med. 1991;20:125-129; Adams et al. Chest. 2000; 117:1345-1352; Patil et al. Arch Int Med. 2003; 163:1180-1186. In hospitalized patients In ER patients In ICU patients In outpatients Goal of COPD Management Overall COPD Control Current Control Future Risk Symptoms Activity Reliever use Lung function Exacerbations Progression of the disease Mortality Medication adverse effects achieving reducing defined by defined by ? GOLD 2011 COPD Chronic disease Tashkin D. N Engl J Med 2010; 363: 1184 Hurst et al, N Engl J Med 2010; 363: 1128-38 progressive nature lung function symptoms comorbidities Exacerbations typically 1 - 3 per year frequency proportional to COPD severity the frequent exacerbator chronic decline resulting in poorer prognosis HRQL hospitalizations mortality COPD exacerbations ASSOCIATION OF DISEASE SEVERITY WITH THE FREQUENCY AND SEVERITY OF EXACERBATIONS DURING THE FIRST YEAR OF FOLLOW-UP IN PATIENTS WITH COPD Hurst J.R. et al., N Engl J Med 2010; 363: 1128-38 (N=945) % of patients (N=900) (N=293) 0 20 40 60 80 100 Percent 0 20 40 60 80 100 Percent 0 20 40 60 80 100 Percent 0 20 40 60 80 100 Percent 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100 Percent Year 1 Year 2 Year 3 23 % 6% 2% 6% 3% 2% 2% 2% 1% 5% 3% 1% 3% 2% 2% 2% 2% 3% 2% 1% 1% 2% 2% 3% 1% 4% 12 % Patients with no exacerbation Patients with 1 exacerbation Patients with 2 exacerbations STABILITY OF THE FREQUENT-EXACERBATION PHENOTYPE IN THE 1679 PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE WHO COMPLETED THE STUDY Hurst J.R. et al., N Engl J Med 2010; 363: 1128-38 Breast Cancer Diseases - 2015 All Breast Cancers ER+ 65-75% HER2+ 15-20% Triple negative 15% HER3+ IGFR1+ p95+ 4% P53mut 30-40 % FGFR1 Ampl 8% PTENloss 30-50% PI3Kmut 10% BRCAMut 8% 12-02 BAC EGFR mut+: Response to TKI 12-00 INTACT 1: Lack of benefit in combination with chemotherapy Population: intention to treat 0.0 0.2 0.4 0.6 0.8 1.0 Survival time (months) 0 4 8 12 16 20 24 Proportion event free 641 463 152 118981093At risk Median survival, months 1-year survival rate, % Log rank vs placebo 9.92 43 0.7759 (p=0.4377) 9.86 41 1.0290 (p=0.3034) 11.07 45 Gefitinib 500 mg/day Gefitinib 250 mg/day Placebo WE DIDNT KNOW ABOUT EGFR MUTATION K Kobayashi et al, P ASCO 2009 PNEUMONIA THROMBOEMBOLISM ACUTE HEART FAILURE METABOLIC ACIDOSIS ANEMIA CAUSES OF EXACERBATION OF RESPIRATORY SYMPTOMS IN CHRONIC PATIENTS BIOCHEMICAL MARKERS OF CARDIAC DYSFUNCTION PREDICT MORTALITY IN ACUTE EXACERBATIONS OF COPD Elevated levels of NT-proBNP and troponin T are strong predictors of early mortality among patients admitted to hospital with acute exacerbations of COPD independently of other known prognostic indicators The pathophysiological basis for this is unknown, but indicates that cardiac involvement in exacerbations of COPD may be an important determinant of prognosis Chang CL et al, Thorax in press UNRECOGNIZED VENTRICULAR DYSFUNCTION IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHF and COPD frequently coexist Ventricular dysfunction worsens survival in patients with COPD Considering the high prevalence and the prognostic implications of ventricular dysfunction, routine assessment with either BNP or echocardiogram should be considered in COPD patients Macchia A et al, ERJ Express - June 23, 2011 THE PROGNOSTIC IMPORTANCE OF LUNG FUNCTION IN PATIENTS ADMITTED WITH HEART FAILURE Prognostic importance for all-cause mortality of lung function variables obtained by spirometry in an unselected group of patients admitted with heart failure (HF) Iversen KK et al, Eur J Heart Fail. 2010 Jul;12(7):685 -91. TARGETING THE LUNG ATTACKS Current management strategiesfor acute asthma and AECOPD within and subsequent to discharge from hospital are suboptimal We suggest that the term lung attack may resonate more with patients and the broader community FitzGerald JM, Thorax May 2011 Vol 66 No 5 Aggiornamento concetti generali sulla componente respiratoria della BPCO Leonardo M. Fabbri DEFINIZIONE Chronic Obstructive Pulmonary Disease (COPD) is a common preventable and treatable disease. It is characterized by chronic respiratory symptoms, particularly dyspnea and persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response of the airways and the lung to cigarette smoke and/or other noxious particles or gases. Exacerbations and significant concomitant disorders contribute to the overall severity in individual patients. 5-yrs mortality The present study analysed data from 20,296 subjects aged 45 yrs at baseline in the Atherosclerosis Risk in Communities Study (ARIC) and the Cardiovascular Health Study (CHS). COPD and chronic comorbidities Exacerbations in COPD Current and future treatment Treatment of co-morbidities of COPD Futuristic treatments CORSO DI AGGIORNAMENTO SU MA