COPD 2015 Guidelines: The 2015 update of the Global Initiative for Chronic Obstructive Lung Disease

In 2011, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) released a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD. It recommended a major revision in the management strategy for COPD that was presented in the original 2001 document. Updated reports released in January 2013, January 2014, and January 2015 are based on scientific literature published since the completion of the 2011 document but maintain the same treatment paradigm. Assessment of COPD is based on the patient’s level of symptoms, future risk of exacerbations, the severity of the spirometric abnormality, and the identification of comorbidities. The 2015 update adds an Appendix on Asthma COPD Overlap Syndrome, material prepared jointly by the GOLD and GINA Science Committees.

 

The GOLD 2015 report is presented as a “strategy document” for health care professionals to use as a tool to implement effective management programs based on available health care systems. The quadrant management strategy tool is designed to be used in any clinical setting; it draws together a measure of the impact of the patient’s symptoms and an assessment of the patient’s risk of having a serious adverse health event in the future. Many studies have assessed the utility/relevance of this new tool. Evidence will continue to be evaluated by the GOLD committees and management strategy recommendations modified as required.

GOLD has been fortunate to have a network of international distinguished health professionals from multiple disciplines. Many of these experts have initiated investigations of the causes and prevalence of COPD in their countries, and have developed innovative approaches for the dissemination and implementation of the GOLD management strategy. The GOLD initiative will continue to work with National Leaders and other interested health care professionals to bring COPD to the attention of governments, public health officials, health care workers, and the general public to raise awareness of the burden of COPD and to develop programs for early detection, prevention and approaches to management.

The GOLD 2015 report: direct link

www.goldcopd.org/uploads/users/files/GOLD_Report_2015_Apr2.pdf

Millions of smokers have undiagnosed COPD

More than half of smokers with normal spirometry had some form of respiratory-related impairment associated with COPD, Dr. Elizabeth A. Regan and the Genetic Epidemiology of COPD (COPDGene) investigators reported in JAMA Internal Medicine.

The findings imply that up to 35 million current and former smokers older than age 55 years in the United States may have some form of respiratory-related impairment associated with COPD that has gone undiagnosed with standard spirometry, the researchers wrote (JAMA Internal Med. 2015 June 22 (doi:10.1001/jamainternmed.2015.2735). 

They found that 55% of current and former smokers older than age 55 years in the study who did not meet the spirometric criteria for COPD (GOLD [Global Initiative for Chronic Obstructive Lung Disease] 0 score) had significant respiratory disease. Their conclusion was based on seven metrics: chronic bronchitis (seen in 12.6% of the GOLD 0 participants), history of severe respiratory exacerbations (seen in 4.3%), dyspnea score of at least 2 (seen in 23.5%), quantitative emphysema exceeding 5% (seen in 9.8%), quantitative gas trapping exceeding 20%, (seen in 12.2%), St. George’s Respiratory Questionnaire (SGRQ) total score exceeding 25 (seen in 26%), and a 6-minute walk distance of less than 350 m (seen in 15.4%).

In 108 never smokers, none had chronic bronchitis or respiratory exacerbations, 3.7% had dyspnea, 8.3% had quantitative emphysema exceeding 5%, 10.2% had quantitative gas trapping exceeding 20%, 3.7% had SGRQ scores above 25, and 3.7% had a 6-minute walk distance of less than 350 m.

Dr. Regan of National Jewish Health and the University of Colorado, Denver, and her associates gathered data from 21 sites across the United States regarding 8,872 current or former smokers who were between the ages of 45 and 80 years and were classified using GOLD spirometric criteria based on postbronchodilator spirometry: 4,388 had a GOLD 0 score, defined as a normal postbronchodilator ratio of FEV₁ to forced vital capacity exceeding 0.7 and an FEV₁ percentage of at least 80% predicted; 794 patients had a GOLD 1 score, defined as mild COPD; and 3,690 had a GOLD 2-4 score, defined as moderate to severe COPD.

Compared with 108 never smokers, the GOLD 0 group had a worse quality of life score (mean SGRQ total score 17.6 for GOLD 0 and 7 for never smokers) and a lower 6-minute walk distance (447 m vs. 493 m). In a subset of 300 patients in the GOLD 0 group whose CT scans were visually scored, 42% (127) had evidence of emphysema or airway thickening. In a subset of 100 never smokers, 10% had evidence of emphysema or airway thickening.

Current guidelines do not include treating smokers with normal spirometry, but physicians recognize the role of medication in treating symptoms and effective treatments need to be determined for GOLD 0 patients, the researchers said. Respiratory medications were being prescribed to 20% of the GOLD 0 participants in COPDGene who had at least one impairment, yet these patients reported more symptoms.

7th Edition of British-Romanian Meetings: Respiratory Medicine Protocols #Vama2015

We are inviting you to the 7th Edition of British-Romanian Meetings: Respiratory Medicine Protocols, organized by our friend doctor Tudor Toma. His message to you: 

Va invitam sa va inscrieti pentru intalnirea de la Vama din acest an, intalnire care va avea loc in perioada 22- 24 octombrie, 2015. Locurile sunt limitate la maxim 60 de participanti. Pentru inscriere folositi pagina de aici sau trimiteti un email de intentie la d-na Lavinia Bodislav (lavinia@rotravelplus.com)

Programul din acest an va fi axat pe ateliere practice si va beneficia de participarea unor lideri de opinie din Romania si Marea Britanie.

Lectori confirmati pentru 22-24 octombrie 2015:
Dr. Neel Sharma, Consultant Respiratory Physician, East Sussex Healthcare.
Dr. Saroj David, Consultant Radiologist, Lewisham & Greenwich NHS Trust, Londra.
Dr. Anastasia Rachmanidou, Consultant ENT Surgeon, Lewisham & Greenwich NHS Trust, Londra.
Dr. Irina Strambu, Bucuresti.
Dr. Andrew Hearn, Respiratory Registrar, Lewisham & Greenwich NHS Trust, Londra.
Dr. Helen Garthwaite, Respiratory Registrar, Royal Free London NHS Foundation, Londra.
Dr. Cynthia Borg, Consultant General and Bariatric Surgery, Lewisham & Greenwich NHS Trust, Londra.

Majoritatea continutului intalnirii si informatii suplimentare vor fi pe retelele de socializare, asadar urmariti pe Twitter @Vama_Workshop informatiile in timp real despre pregatirea acestui simpozion.

Va multumim pentru participare si va asteptam cu drag la #Vama2015. 

Doctor Tudor Toma 

2015 guidelines for the treatment of idiopathic pulmonary fibrosis released by leading respiratory societies

Updated guidelines on the treatment of idiopathic pulmonary fibrosis (IPF) have been released by an international group of leading respiratory societies, The new guidelines, issued by the American Thoracic Society, the European Respiratory Society, the Japanese Respiratory Society, and the Latin American Thoracic Association, were published in the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine.

"In these updated guidelines, we analyzed new evidence reported since our 2011 guideline was issued and updated our treatment recommendations accordingly," said Ganesh Raghu, MD, Professor of Medicine, University of Washington, director of the Center for Interstitial Lung Disease, UW Medicine at the University of Washington Medical Center, and chair of the committee that produced the guidelines. "The updated guidelines do not recommend one treatment regimen over another. All of these recommendations must be weighed individually, considering all the factors used to grade each one, including the confidence in effect estimates, evidence from outcomes studies, desirable and undesirable consequences of treatment, treatment costs, the implications of treatment on health equity, and the feasibility of treatment," Raghu added.

Evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach, with recommendations rated as either "strong" or "conditional." Conditional recommendations are synonymous with weak recommendations.

The following recommendations are new or revised from the 2011 guidelines:

• The recommendation against the use of the following agents for the treatment of IPF is strong:
  • Anticoagulation (warfarin)
  • Imatinib, a selective tyrosine kinase inhibitor against platelet-derived growth factor (PDGF) receptors
  • Combination prednisone, azathioprine, and N-acetylcysteine
  • Selective endothelin receptor antagonist (ambrisentan)
• The recommendation for the use of the following agents for the treatment of IPF is conditional:
  • Nintedanib, a tyrosine kinase inhibitor that targets multiple tyrosine kinases, including vascular endothelial growth factor, fibroblast growth factor, and PDGF receptors
  • Pirfenidone
• The recommendation against the use of the following agents for the treatment of IPF is conditional:
  • Phosphodiesterase-5 inhibitor (sildenafil)
  • Dual endothelin receptor antagonists (macitentan, bosentan)

Recommendations remaining unchanged from the 2011 guidelines include a conditional recommendation against the use of N-acetylcysteine monotherapy for IPF and a conditional recommendation for the use of antiacid therapy.

"Our systematic review of the available evidence on IPF treatments points to the need for additional research and long-term studies of their safety and efficacy," said Dr. Raghu. "This is especially true for treatments that received conditional recommendations in the guidelines. The guidelines empower the clinician to make the most appropriate treatment choices for the patient confronted with IPF and encourage shared decision-making with the well informed patient to choose the most appropriate treatment options tailored to the individual patient's needs," emphasized Raghu.

WHO Report on the global tobacco epidemic 2015

Too few governments levy appropriate levels of tax on cigarettes and other tobacco products. They therefore miss out on a proven, low-cost measure to curb demand for tobacco, save lives and generate funds for stronger health services, according to the "WHO Report on the global tobacco epidemic 2015".

 

The report focuses on raising taxes on tobacco. Although 33 countries impose taxes that represent more than 75% of the retail price of a packet of cigarettes, many countries have extremely low tax rates. Some have no special tax on tobacco products at all.

“Raising taxes on tobacco products is one of the most effective – and cost-effective – ways to reduce consumption of products that kill, while also generating substantial revenue,” says Dr Margaret Chan, WHO Director-General. “I encourage all governments to look at the evidence, not the industry’s arguments, and adopt one of the best win-win policy options available for health.”

Strategies to support the implementation of demand reduction measures contained within the WHO Framework Convention on Tobacco Control (WHO FCTC), such as the “MPOWER” package, have helped save millions of lives in the past decade. MPOWER was established in 2008 to promote government action on 6 tobacco control strategies – 1 for each letter of the MPOWER acronym – to stamp out the tobacco epidemic, namely to:

• Monitor tobacco use and prevention policies;
• Protect people from tobacco smoke;
• Offer help to quit tobacco use;
• Warn people about the dangers of tobacco;
• Enforce bans on tobacco advertising, promotion and sponsorship; and
• Raise taxes on tobacco.

The main findings of the report, funded by Bloomberg Philanthropies, include the fact that raising taxes is the least implemented MPOWER measure in terms of population coverage, and the one that has seen the least improvement in terms of government action since 2008. However, by 2014, 11 countries had raised taxes so that they represent more than 75% of the retail price of a packet of cigarettes, joining the 22 countries that had similarly high taxes in place in 2008.

Dr Douglas Bettcher, Director of WHO’s Department for the Prevention of Noncommunicable Diseases (NCDs), says higher tobacco taxes and prices are proven methods to reduce consumption and promote quitting the use of tobacco products.

“Evidence from countries such as China and France shows that higher tobacco product prices linked to increased taxes lead to declines in smoking prevalence and tobacco-related harm, such as lung cancer deaths,” says Dr Bettcher.

Dr Vera da Costa e Silva, Head of the WHO FCTC Secretariat, notes that the Convention offers governments policies to curb illicit trade in tobacco products to reduce demand and boost tax revenues from tobacco sales. “Countries should consider implementing the provisions of the Protocol to Eliminate Illicit Trade in Tobacco Products to confront the illegal market,” she adds.

Tobacco taxation could also be a key source of funding for implementing the post-2015 Sustainable Development Goals.

Tobacco-related illness is one of the biggest public health threats the world has ever faced. Approximately 1 person dies from a tobacco-related disease every 6 seconds, equivalent to around 6 million people a year. That is forecast to rise to more than 8 million people a year by 2030, unless strong measures are taken to control the epidemic.

Tobacco use is also one of the 4 main risk factors behind the global epidemic of noncommunicable diseases, primarily cancers, cardiovascular and lung diseases, and diabetes. In 2012, these diseases killed 16 million people prematurely (before the age of 70 years), with more than 80% occurring in low- and middle-income countries.

The Anatomy of Healthcare Startups

Venture capital-backed healthcare startups are addressing diseases and conditions affecting virtually every part of the human body. 

NEW TITLES WITH FIRST JOURNAL IMPACT FACTOR. 2014 Release

Librarians and information scientists have been evaluating journals for at least 75 years. Gross and Gross conducted a classic study of citation patterns in the '20s. Others, including Estelle Brodman with her studies in the '40s of physiology journals and subsequent reviews of the process, followed this lead. However, the advent of the Thomson Reuters citation indexes made it possible to do computer-compiled statistical reports not only on the output of journals but also in terms of citation frequency. And in the '60s we invented the journal "impact factor." After using journal statistical data in-house to compile the Science Citation Index® (SCI®) for many years, Thomson Reuters began to publish Journal Citation Reports® (JCR®) in 1975 as part of the SCI and the Social Sciences Citation Index® (SSCI®).

Informed and careful use of these impact data is essential. Users may be tempted to jump to ill-formed conclusions based on impact factor statistics unless several caveats are considered.