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Điều trị giảm đợt cấp copd tái phát
1. Điều trị giảm đợt cấp tái phát
TS BS Nguyễn Văn Thành
PCT Hội Lao và Bệnh phổi VN
2015
Đợt cấp COPD
2. TÁC ĐỘNG CỦA ĐỢT CẤP TRÊN BỆNH NHÂN
Wedzicha JA and Seemungal TA. Lancet 2007; 370: 786–796
Higher mortality
Faster decline
in lung function
Poorer quality
of life
Greater airway
inflammation
Patients with frequent exacerbations
ĐIỀU TRỊ PHÒNG
3. Tác động lên chất lượng cuộc sống
TERENCE A. R. SEEMUNGAL et al. AM J RESPIR CRIT CARE MED 1998;157:1418–1422.
4. TIÊN LƯỢNG TỬ VONG
J J Soler-Catalun˜a et al. Thorax 2005;60:925–931
Tần số đợt cấp Mức độ nặng đợt cấp
6. AI SẼ LÀ NGƯỜI NHIỀU ĐỢT CẤP
John R. Hurst et al. N Engl J Med 2010
GOLD III [1.36 (1.07–1.74)], GOLD IV [2.90 (1.98–4.25)],
7. Tiền sử đợt cấp: yếu tố nguy cơ
để điều trị tích cực
P<0.001
5.72
P<0.001
2.24
P<0.001
2.55
0
1
2
3
4
5
6
7
≥2 vs 0 1 vs 0 ≥2 vs 1
OddsRatio
Exacerbations during previous year
Overall model
P<0.001
Hurst JR et al. N Engl J Med 2010; 363: 1128–1138
8. Agusti A, et al. Eur Respir J 2013; 42: 636
TÍNHỔNĐỊNH
CỦAPHENOTYPE
9. CẦN CHÚ Ý
COPD nặng (III, IV hoặc C, D)
Nhiều đợt cấp (≥ 2/năm)
Có đợt cấp nặng nhập viện (≥1 /năm)
12. ICS/LABA, ICS vs placebo
Szafranski W et al. Eur Respir J 2003;21:74–81.
Calverley PM et al. Eur Respir J 2003;22:912–919.
13. TORCH study: LABA+ICS giảm nguy
cơ đợt cấp trung bình hoặc nặng
Calverley PM et al. N Engl J Med 2007; 356: 775–789
* P<0.05 vs placebo; †P=0.002 vs
salmeterol; ‡P=0.024 vs fluticasone
*, †, ‡
*
*
1.13
0.97
0.93
0.85
0
0.2
0.4
0.6
0.8
1.0
1.2
Annualrateofexacerbataions
Placebo (N=1524)
Salmeterol (N=1521)
Fluticasone (N=1534)
Combination therapy (N=1533)
25% reduction
14. Sharafkhaneh A et al. Int J Chron Obstruct Pulmon Dis 2010; 5: 357–366
a,b
a,b
a,b a,b
aSignificant vs placebo
bSignificant vs formoterol
Inhaled corticosteroids (ICS) alone or in combination with
long-acting bronchodilators reduce exacerbations of COPD
15. Không Fluticasone
E F M Wouters et al. Thorax 2005;60:480–487.
FEV1 ≥50% hoặc <50%
Conclusions: Withdrawal of FP in
COPD patients using SFC resulted in
acute and persistent deterioration in
lung function and dyspnoea and in an
increase in mild exacerbations and
percentage of disturbed nights. This
study clearly indicates a key role for
ICS in the management of COPD as
their discontinuation leads to
disease deterioration, even under
treatment with a LABA.
17. Miravitlles M and Anzueto A. Int J COPD 2009; 4: 185–201
Control
Tiotropium
Placebo
0.85 0.85
Salmeterol/
fluticasone
combination
0.73
1.13
-25
-14
UPLIFT and TORCH:
Hiệu quả giảm đợt cấp
18. Use of tiotropium for acute exacerbations
can reduce hospitalisation rates
Drescher GS et al. Respir Care 2008; 53: 1678–1684*P<0.05 for 2004 (ipratropium) vs 2006 (tiotropium)
Early addition of maintenance-treatment
tiotropium to a respiratory-therapist-
directed bronchodilator protocol for
patients hospitalized for COPD
exacerbation reduced costs and
produced no safety concerns
28. Hiệu quả Roflumilast trên đợt cấp
0.00
0.50
1.00
1.50
2.00
2.50
All patients Not frequent exacerbators Frequent exacerbators
Placebo
Roflumilast
AURA (M2-124) & HERMES (M2-125)
Pooled post-hoc analysis
Frequent exacerbators
≥2 exacerbations
in previous year
Not frequent exacerbators
<2 exacerbations
in previous year
Bateman ED et al. ERS 2010; P4003; Abstract + poster
Meanrateofmoderateorsevere
exacerbationsperyear
2.5
2.0
1.5
1.0
0.5
0
All patients
Placebo
Roflumilast
Δ = -16.9%
CI -25, -8.0
P=0.0003
Δ = -16.5%
CI -26, -5.0
P=0.006
Δ = -22.3%
CI -33, -9.0
P=0.002
29. PDE4 inhibitors: identifying patients most
likely to reduce exacerbation frequency
Rennard SI et al. Respir Res 2011; 12: 18
Overall
Female
Male
Current smokers
Former smokers
Inhaled corticosteroid – yes
Inhlaed corticosteroid – no
Anticholinergic – yes
Anticholinergic – no
Completers
Non-completers
Very severe COPD
Severe COPD
Emphysema
Chronic bronchitis ± emphysema
Chronic bronchitis ± emphysema + inhaled corticosteroid
Chronic bronchitis ± emphysema – inhaled corticosteroid
Cough score ≥1
Cough score <1
Sputum score ≥1
Sputum score <1
Favours roflumilast Favours placebo
0 0.2 0.4 0.6 0.8 1.2 1.41
Rate ratio (95% CI)
Reduction in exacerbation rate
31. Azithromycin
azithromycin, at a dose of 250 mg daily for 1 year in addition to their usual care
Richard K. Albert et al. N Engl J Med 2011
32. Fluoroquinolones làm chậm
xuất hiện đợt cấp mới
Derived from data in Wilson R et al. CHEST 2004; 125: 953–964
*Composite event: treatment failure and/or new exacerbation and/or any further antibiotic treatment; Reporting period: from
randomisation up to 9 months post-study therapy; ‡Log rank test showed statistically significant superiority of moxifloxacin for up to 5
months post-treatment
0
20
40
60
80
100
1 2 3 4 5 6 7 8 9 10
Time since randomisation (months)
P=0.03‡
Moxifloxacin
Comparator
Patientsnotexperiencing
compositeevent(%)
(N=324)
(N=319)
Time to next exacerbation was significantly (P=0.03) longer with moxifloxacin2
• Median: moxifloxacin = 131.0 days; comparator = 103.5 days
• Mean: moxifloxacin = 132.8 days; comparator = 118.0 days
33. CD. Kháng sinh dự phòng đợt cấp
Herath SC, Poole P. 2013, Issue 11
34. PPV23 vaccin
PPV should be given to patients with COPD aged ,65 years, especially if they have
severe airflow obstruction. This vaccination could prevent episodes of
pneumococcal pneumonia frequently labelled as ‘‘pneumonia of unknown etiology’’
I Alfageme et al. Thorax 2006
35. Influenza vaccin for COPD
It appears, from the limited number of studies performed, that inactivated vaccine
reduces exacerbations in COPD patients. The size of effect was similar to that seen in
large observational studies, and was due to a reduction in exacerbations occurring three
or more weeks after vaccination, and due to influenza
36. American College of Chest Physicians 2014
Khuyến cáo mạnh: LAMA, LABA, ICS+LABA
Khuyến cáo trung bình: SAMA, SABA, PDE4,
Theo, N-acetl, Carbos, Macro
38. Quản lý tốt AE - COPD
John R Hurst et al. BMC Medicine 2009
SỚM
39. Tóm tắt
Nhiều đợt cấp là một phenotype, là yếu tố
tiên lượng mạnh nhất khả năng xuất hiện
đợt cấp về sau.
Giảm đợt cấp bằng thuốc cần tuân thủ
điều trị, điều trị tích cực đợt cấp và sử
dụng một số thuốc đã được chứng minh
có hiệu quả giảm đợt cấp để điều trị lâu
dài cho COPD giai đoạn ổn định.
