Presentazione sul tema: "MALATTIE RESPIRATORIE"— Transcript della presentazione:
1MALATTIE RESPIRATORIE Modena 6-7/8-9 Settembre Corso di Aggiornamento suMALATTIE RESPIRATORIERidefinizione della BPCO e delle riacutizzazioni dei sintomi in pazienti con BPCO
2TREATMENT TARGETS IN COPD: CURRENT AND EVOLVING MANAGEMENT OPTIONS COPD and chronic comorbiditiesExacerbations in COPDCurrent and future treatmentTreatment of co-morbidities of COPDFuturistic treatmentsDiabetes Intervention Study (1)L’importanza della glicemia postprandiale come fattore di rischio cardiovascolare è stata dimostrata anche per i pazienti diabetici Tipo 2 in questo studio condotto in 1139 pazienti diabetici di Tipo 2 di nuova diagnosi.
3OUTCOME OF COPD EXACERBATIONS Hospital mortality20%-24%(1 year)In ICU patientsIn hospitalizedpatientsHospital mortality2.5%-10%(5 days)Treatment failure is defined as not responsive to initial treatment(s).Outcomes = health utilizations.This slide shows outcomes of patients with acute exacerbations: 20-24% of patients in the ICU with an exacerbation died; 6-12% of patients in general hospital beds, not ICU beds, died. Of those who visited the ER for an acute exacerbation, 22-32% of those patients had to revisit the emergency room after being discharged. Those who were treated as outpatients 13-33% of those patients did not response to initial treatments and needed further medical intervention.Main point: Acute exacerbations are a serious matter and should be of concern to the health care provider.Relapse (repeat ER visit)22%-32%(14 days)In ER patientsTreatment failure rate13%-33%(14 days)In outpatientsSeneff MG, Wagner DP, Wagner RP, Zimmerman JE, Knaus WA. Hospital and 1-year survival of patients admitted to intensive care units with acute exacerbation of chronic obstructive pulmonary disease. JAMA. 1995;274:Murata GH, Gorby MS, Chick TW, Halperin AK. Treatment of decompensated chronic obstructive pulmonary disease in the emergency department—correlation between clinical features and prognosis. Ann Emerg Med. 1991;20:Adams SG, Melo J, Luther M, Anzueto A. Antibiotics are associated with lower relapse rates in outpatients with acute exacerbations of COPD. Chest. 2000;117:Patil SP, Krishnan JA, Lechtzin N, Diette GB. In-hospital mortality following acute exacerbations of chronic obstructive pulmonary disease. Arch Int Med. 2003; 160:Seneff et al. JAMA. 1995; 274: ; Murata et al. Ann Emerg Med. 1991;20: ; Adams et al. Chest. 2000; 117: ; Patil et al. Arch Int Med. 2003; 163:
4Goal of COPD Management Overall COPD ControlachievingreducingCurrent ControlFuture Riskdefined bydefined bySymptomsReliever useExacerbationsMortalityActivityLung functionProgressionof the diseaseMedicationadverse effects????? GOLD 2011
5COPD COPD exacerbations Chronic disease Exacerbations progressive naturelung functionsymptomscomorbiditiestypically per yearfrequency proportional to COPD severitythe frequent exacerbatorchronic decline resultingin poorer prognosis HRQL hospitalizations mortalityVestbo J. What is an exacerbation of COPD? European Respiratory Review 2004;13:6–13Synopsis: This review explores the different ways in which exacerbations of COPD are defined and examines the aetiology of these events and the burden they impose on patients and society in terms of morbidity, mortality, HRQL and costs. The impact of ICS and ICS/LABA combinations, including Symbicort, on exacerbations and related outcomes are discussed.Published abstract: Patients with chronic obstructive pulmonary disease (COPD) experience acute exacerbations that increase in frequency with disease severity. Exacerbations may be defined in various ways, depending on the needs of researchers, clinicians, patients or healthcare payers. At present, action-based definitions (based on the need for treatment with oral corticosteroids, antibiotics, or both, and/or hospitalisation due to respiratory symptoms) are the best available for the purposes of comparing medical treatments that may reduce or prevent exacerbations. Further research is required to elucidate the mechanisms underlying COPD exacerbations, including the possible role of eosinophils. Exacerbations of COPD accelerate lung function decline, increase the risk of hospitalisation and death, cause sustained impairment of health status, and generate substantial socio-economic costs. Combination therapy with inhaled corticosteroids and long-acting β2-agonists reduces the frequency of exacerbations, in addition to improving lung function, symptoms and health status and, possibly, lowering the risk of mortality. In summary, a greater awareness of the pathogenesis of exacerbations and their impact is necessary to encourage optimal treatment. Interventions that effectively prevent or treat exacerbations, such as inhaled corticosteroids/long-acting β2-agonists combination therapy, have the potential to significantly reduce the impact of chronic obstructive pulmonary disease on patients and society.This material has been supplied by AstraZeneca to you under licence from the copyright owner, and may not be recopied or redistributed outside AstraZeneca without permission from the copyright owner.Tashkin D. N Engl J Med 2010; 363: 1184Hurst et al, N Engl J Med 2010; 363:5
6Hurst J.R. et al., N Engl J Med 2010; 363: 1128-38 ASSOCIATION OF DISEASE SEVERITY WITH THE FREQUENCY AND SEVERITY OF EXACERBATIONS DURING THE FIRST YEAR OF FOLLOW-UP IN PATIENTS WITH COPD% of patients(N=945)(N=900)(N=293)Hurst J.R. et al., N Engl J Med 2010; 363:
7STABILITY OF THE FREQUENT-EXACERBATION PHENOTYPE IN THE 1679 PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE WHO COMPLETED THE STUDY20406080100PercentYear 1Year 2Year 323%6%2%3%1%5%4%12%Patients with no exacerbationPatients with 1 exacerbationPatients with ≥ 2 exacerbationsHurst J.R. et al., N Engl J Med 2010; 363:
8Breast Cancer Diseases - 2015 All Breast CancersPI3Kmut10%ER+65-75%HER3+IGFR1+HER2+15-20%p95+4%P53mut30-40 %FGFR1Ampl 8%Triple negative15%PTENloss30-50%BRCAMut8%
10INTACT 1: Lack of benefit in combination with chemotherapy Median survival, months1-year survival rate, %Log rank vs placebo9.92430.7759(p=0.4377)9.86411.0290(p=0.3034)11.0745Proportion event free1.0WE DIDN’T KNOW ABOUTEGFR MUTATION0.8Gefitinib 500 mg/dayGefitinib 250 mg/dayPlacebo0.60.4At neither dose did ZD1839 improve survival when added to gemcitabine plus cisplatin vs gemcitabine plus cisplatin alone.Median survival ranged from 9.9 to 11.1 months, with no significant difference between the three treatment groups.0.20.04812162024Survival time (months)At risk109389864146315211Population: intention to treat10
12CAUSES OF EXACERBATION OF RESPIRATORY SYMPTOMS IN CHRONIC PATIENTS PNEUMONIATHROMBOEMBOLISMACUTE HEART FAILUREMETABOLIC ACIDOSISANEMIADiabetes Intervention Study (1)L’importanza della glicemia postprandiale come fattore di rischio cardiovascolare è stata dimostrata anche per i pazienti diabetici Tipo 2 in questo studio condotto in 1139 pazienti diabetici di Tipo 2 di nuova diagnosi.
13Biochemical Markers of Cardiac Dysfunction Predict Mortality in Acute Exacerbations of COPDElevated 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 indicatorsThe pathophysiological basis for this is unknown, but indicates that cardiac involvement in exacerbations of COPD may be an important determinant of prognosisChang CL et al, Thorax in press
14CHF and COPD frequently coexist UNRECOGNIZED VENTRICULAR DYSFUNCTION IN CHRONIC OBSTRUCTIVE PULMONARY DISEASECHF and COPD frequently coexistVentricular dysfunction worsens survival in patients with COPDConsidering the high prevalence and the prognostic implications of ventricular dysfunction, routine assessment with either BNP or echocardiogram should be considered in COPD patientsMacchia A et al, ERJ Express - June 23, 2011
15Iversen KK et al, Eur J Heart Fail. 2010 Jul;12(7):685-91. The prognostic importance of lung function in patients admitted with heart failurePrognostic 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 Jul;12(7):
16TARGETING THE LUNG ATTACKS FitzGerald JM, Thorax May 2011 Vol 66 No 5 Current management strategiesfor acute asthma and AECOPD within and subsequent to discharge from hospital are suboptimalWe suggest that the term ‘lung attack’ may resonate more with patients and the broader communityFitzGerald JM, Thorax May 2011 Vol 66 No 5
17 Aggiornamento concetti generali sulla componente respiratoria della BPCO Leonardo M. Fabbri DEFINIZIONEChronic 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.
195-yrs mortalityThe present study analysed data from 20,296 subjects aged >45 yrs at baseline inthe Atherosclerosis Risk in Communities Study (ARIC) and the CardiovascularHealth Study (CHS).
20COPD and chronic comorbidities Exacerbations in COPD CORSO DI AGGIORNAMENTO SU MALATTIE RESPIRATORIE Modena Luglio 2011 INTRODUZIONE E LINEE GUIDA PER LA BPCO Leonardo M. FabbriCOPD and chronic comorbiditiesExacerbations in COPDCurrent and future treatmentTreatment of co-morbidities of COPDFuturistic treatmentsDiabetes Intervention Study (1)L’importanza della glicemia postprandiale come fattore di rischio cardiovascolare è stata dimostrata anche per i pazienti diabetici Tipo 2 in questo studio condotto in 1139 pazienti diabetici di Tipo 2 di nuova diagnosi.
21SYSTEMIC EFFECTS AND COMORBIDITIES OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE Barnes PJ et al., Eur Respir J 2009;33:1165–1185
22Severity of airflow limitation Frequency and severity of exacerbations Comorbidities
23MALATTIE RESPIRATORIE Modena Luglio Corso di Aggiornamento suMALATTIE RESPIRATORIERidefinizione della BPCO e delle riacutizzazioni dei sintomi in pazienti con BPCO