Stepping Down Inhaled Therapy in COPD Patients
POSTER SUBMITTED TO PCRS-UK ANNUAL CONFERENCE (2014)
Authors:
Canavan M
Affiliation of first author:
The Practice Lincoln Green, Leeds
Brief outline of context:
There is an increased risk of serious but non-fatal pneumonia in COPD patients prescribed ICS . Kew et al (2014). Patients are often over treated with ICS the aim was to identify those patients and step down inhaled therapy.
Brief outline of problem:
Many patients with COPD are over treated with ICS, this could be due to a lack of awareness of other causes for respiratory symptoms.
Assessment of problem and analysis of its causes:
Airway reflux is an unrecognised agent provoking the symptoms of respiratory disease. Airway reflux is unlike gastro-oesophageal reflux disease (GORD). GORD is liquid acid reflux causing heartburn and indigestion. Airway reflux consists of mainly gaseous non-acid mist which, when deposited in the airways leads to inflammation, fibrosis, bronchoconstriction and cough. (Morice, 2013)
Strategy for change:
We began to use the Hull cough questionnaire in practice with COPD patients complaining of cough to identify patients with airway reflux. Patients identified as having reflux were treated as per protocol fromhttp://www.issc.info/. Once the symptoms improved we proceeded to stop combined inhalers in favour of LABA and/or LAMA.
Measurement of improvement:
Exacerbations were reduced and symptoms improved as demonstrated by improved CAT scores. A CAT score of minus 2 is significant, CAT scores improved by up to 10 once reflux was managed. Using the GSK POINTS audit we found that in the 12 month period 17 COPD patients had stopped the combined inhaler in patients who had FEV1 above 50%. GOLD 2014 recommended that COPD is not managed solely on FEV1 as this is a poor descriptor of disease status. This was also taken into account when discontinuing combined inhaler.
Effects of changes:
Addressing airway reflux improved quality of life and also reduced costs. For 2 consecutive years The practice made the most savings relating to respiratory care within the CCG resulting in an underspend. Lincoln Green saved £12,071 on respiratory medicines, whereas most practices within the CCG increased spending on average £6,680
Lessons learnt:
Rather than increasing inhaled therapy in the first instance, other conditions such as airway reflux and rhinitis should be assessed.
Message for others:
The Hull cough questionnaire is quick and easy tool that can be implemented in practice for respiratory patients with a cough. Addressing airway reflux improves quality of life, reduces cost and also side effects from potent steroids. This can help with the GRASP tool for COPD to reduce the number of patients with FEV1 above 50% on combination inhalers.
Canavan M
Affiliation of first author:
The Practice Lincoln Green, Leeds
Brief outline of context:
There is an increased risk of serious but non-fatal pneumonia in COPD patients prescribed ICS . Kew et al (2014). Patients are often over treated with ICS the aim was to identify those patients and step down inhaled therapy.
Brief outline of problem:
Many patients with COPD are over treated with ICS, this could be due to a lack of awareness of other causes for respiratory symptoms.
Assessment of problem and analysis of its causes:
Airway reflux is an unrecognised agent provoking the symptoms of respiratory disease. Airway reflux is unlike gastro-oesophageal reflux disease (GORD). GORD is liquid acid reflux causing heartburn and indigestion. Airway reflux consists of mainly gaseous non-acid mist which, when deposited in the airways leads to inflammation, fibrosis, bronchoconstriction and cough. (Morice, 2013)
Strategy for change:
We began to use the Hull cough questionnaire in practice with COPD patients complaining of cough to identify patients with airway reflux. Patients identified as having reflux were treated as per protocol fromhttp://www.issc.info/. Once the symptoms improved we proceeded to stop combined inhalers in favour of LABA and/or LAMA.
Measurement of improvement:
Exacerbations were reduced and symptoms improved as demonstrated by improved CAT scores. A CAT score of minus 2 is significant, CAT scores improved by up to 10 once reflux was managed. Using the GSK POINTS audit we found that in the 12 month period 17 COPD patients had stopped the combined inhaler in patients who had FEV1 above 50%. GOLD 2014 recommended that COPD is not managed solely on FEV1 as this is a poor descriptor of disease status. This was also taken into account when discontinuing combined inhaler.
Effects of changes:
Addressing airway reflux improved quality of life and also reduced costs. For 2 consecutive years The practice made the most savings relating to respiratory care within the CCG resulting in an underspend. Lincoln Green saved £12,071 on respiratory medicines, whereas most practices within the CCG increased spending on average £6,680
Lessons learnt:
Rather than increasing inhaled therapy in the first instance, other conditions such as airway reflux and rhinitis should be assessed.
Message for others:
The Hull cough questionnaire is quick and easy tool that can be implemented in practice for respiratory patients with a cough. Addressing airway reflux improves quality of life, reduces cost and also side effects from potent steroids. This can help with the GRASP tool for COPD to reduce the number of patients with FEV1 above 50% on combination inhalers.
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