COPD the New Epidemic

COPD The New Epidemic

Peter Lin MD CCFP Director Primary Care Initiatives Canadian Heart Research Centre Conflict Disclosure Information

Speaker: Dr. Peter Lin

Title of Talk: COPD – The New Epidemic

Financial Disclosure Company

Grants / Research Support None Speakers Honorarium Astrazeneca, BMS, Takeda Boeringher Ingelheim, Abbott Eli Lilly, Amgen, Mylan, Janssen Forest Laboratories, J&J, Merck, Novartis, Pfizer, Servier, Sanofi Consulting Fees None Patents None Other None Mitigating Potential Bias

• Only published data will be presented in this program and recommendations will be based on published Guidelines Learning Objectives:

By the end of this workshop you will be able to:

1. Make appropriate diagnosis 2. Understand appropriate testing 3. Be able to incorporate guidelines into the management of your patients 4. Understand the role of new therapies for the management of your patients Percent Change in Age-Adjusted Death Rates, U.S., 1965 – 1998 (Proportion of 1965 Rate)

Air trapping Mr. CO

• 76 year old man • Short of breath • Had Negative Cardiac workup • Smoker 40 pk years • Coughs most days – some sputum •Meds: • ARB, Statin, ASA, Vitamins Global Strategy for Diagnosis, Management and Prevention of COPD Diagnosis of COPD

EXPOSURE SYMPTOMS TO RISK FACTORS shortness of breath tobacco chronic cough occupation sputum indoor/outdoor pollution

SPIROMETRY: Required to establish diagnosis

12 Spirometry: Normal Trace Showing

FEV1 and FVC

5 FVC

3 FEV1 = 4L FVC = 5L Volume, liters2

FEV1/FVC = 0.8 1

1 23456 Time, sec

5 Normal

3 FEV1 = 1.8L 2 Obstructive

Volume, liters FVC = 3.2L < 0.70 1 FEV1/FVC = 0.56

123456

Time, seconds

• Walking can’t keep up with his wife Assessing Disability in COPD Mr. CO

• FEV1 is 70% predicted Global Strategy for Diagnosis, Management and Prevention of COPD Classification of Severity of Airflow

Limitation in COPD* based on FEV1

GOLD 1: Mild FEV1 > 80% predicted

GOLD 2: Moderate 50% < FEV1 < 80% predicted

GOLD 3: Severe 30% < FEV1 < 50% predicted

GOLD 4: Very Severe FEV1 < 30% predicted

*Based on Post-Bronchodilator FEV1

Limitation in COPD* based on FEV1

GOLD 1: Mild FEV1 > 80% predicted

GOLD 2: Moderate 50% < FEV1 < 80% predicted

GOLD 3: Severe 30% < FEV1 < 50% predicted

GOLD 4: Very Severe FEV1 < 30% predicted

*Based on Post-Bronchodilator FEV1

Limitation in COPD* based on FEV1 Mr. CO FEV1 = 70%

GOLD 1: Mild FEV1 > 80% predicted

GOLD 2: Moderate 50% < FEV1 < 80% predicted

GOLD 3: Severe 30% < FEV1 < 50% predicted

GOLD 4: Very Severe FEV1 < 30% predicted

*Based on Post-Bronchodilator FEV1

• 5 years he had 3 exacerbations What is the impact of exacerbations on mortality?  50% of COPD patients are dead within 4 years of being admitted for first time with COPD1

A= No Exacerbations

B= 1-2 Exacerbations

C= > 3 Exacerbations

1.Suissa S, Dell’Aniello S, Ernst P. Thorax. doi: 10.1136/thorax.jnl-2011-201518, 2.Soler-Cataluna JJ, et al. Thorax. 2005;60:925-931. Suissa S et al. Thorax 2012;67:957-963 Suissa S et al. Thorax 2012;67:957-963 Daily rates of death (per 10 000 per day) in the 90-day period after onset of severe chronic obstructive pulmonary disease exacerbation.

Suissa S et al. Thorax 2012;67:957-963

80 *

Hazard ratio: 0.86 CI: 0.81-0.91 40 *p<0.001

Probability of 20 exacerbation (%)

0 0 61218243036 42 48 Month No. at risk Tiotropium 2986 1996 1486 1223 983 838 709 610 26 Placebo 3006 1815 1284 1010 776 634 545 460 21

Tashkin DP, et al. N Engl J Med. 2008;359:1543-1554. LAMA vs LAMA + LABA Formoterol + Tiotropium

‡ Trough FEV1: Change from Total COPD Symptom Score baseline AM/PM 250 † AM PM average * n=108 0 n=118 n=106* 200 n=121* ‐0.2 (mL) 1 150 ‐0.4 n=127 n=121 n=121 n=129 ‐0.6 100 ‐0.8 in trough FEV

Change from baseline 50 ‐1.0

‐1.2 0 * Week 4 Week 8 Week 12 Last visit ‐1.4 * * ‐1.6 Mean change in symptom score

Formoterol (12 µg b.i.d.) + Tiotropium (18 µg o.d.) tiotropium (18 µg o.d.)

*p<0.05; †p<0.001 vs. tiotropium; ‡ sum of scores for dyspnea (0 = none to 4 = severe), wheezing, cough, and chest ghtness (0 = none to 3 = very uncomfortable). Tashkin DP, et al.: COPD 2009; 6(1):17‐25. TORCH – ICS vs LABA vs Combo

Calverley PMA et al. N Engl J Med 2007;356:775-789 LAMA vs LAMA + ICS + LABA

0.4 62% reduction in rate of severe exacerbation Ratio: 0.38 (95% CI: 0.25–0.57) P < 0.001 BUD/FORM + TIO PBO + TIO 0.3

0.2 Exacerbations/patient 0.1

0.0 0153045607590 Poisson regression Days since randomisation BUD/FORM=budesonide/formoterol (320/9 μg bid); PBO = placebo; TIO = tiotropium (18 μg od) Welte T, et al. Am J Respir Crit Care Med. 2009;180:741-750. Global Strategy for Diagnosis, Management and Prevention of COPD Combined Assessment of COPD

4 ICS + LABA ICS + LABA >2 GOLD (C)or and/or(D) LAMA LAMA FEV1 3 <50% Predicted Exacerbations

2 SAMA prn LABA 1 (A)or (B)or SABA prn LAMA 1 0

mMRC 0-1 mMRC > 2 CAT < 10 CAT > 10 Symptoms

© 2017 Global Initiative for Chronic Obstructive Lung Disease Bronchodilator 2 Bronchodilators Bronchodilators + ICS LAMA or LABA LAMA + LABA LAMA + LABA + ICS Pharmacotherapy Indicated for COPD in Canada§ BRONCHODILATORS

SHORT‐ACTING BETA 2‐AGONISTS LONG‐ACTING BETA 2‐AGONISTS

SHORT‐ LONG‐ACTING ANTICHOLINERGICS

ACTING Umeclidinium (bromide) ANTICHOLINE RGICS

INCRUISE Ellipta 62.5 mcg

CORTICOSTERIODS/LONG‐ACTING BETA 2‐AGONISTS Budesonide/Formoterol (fumarate)

ANTICHOLINERGICS AND LONG‐ACTING BETA 2‐AGONISTS

Ipratropium (bromide)/ Glycopyrronium (bromide)/ Umeclidinium (bromide)/ Tiotropium (bromide)/ Aclidinium (bromide)/ Salbutamol (sulfate) Indacaterol (maleate) Vilanterol (trifenatate) Olodaterol (hydrochloride) Formoterol (fumarate)

DUAKLIR™ COMBIVENT INSPIOLTO™ Genuair 400/ 12 Respimat 20/100 mcg Respimat 2.5/2.5 mcg mcg § Chart not representative of all approved COPD medications Canada. www.hc-sc.gc.ca accessed June 24, 2015 Treatments for COPD Abbreviation Full name Examples Brand (Device) Budesonide Pulmicort (Turbuhaler) Inhaled ICS Fluticasone Proprionate Flovent (Diskus) corticosteroid Fluticasone Furoate (Ellipta) Long-acting anticholinergic Tiotropium Spiriva (Respimat) LAMA (also known as Glycopyrronium Seebri (Breezhaler) LAAC long-acting Aclidinium Bromide Tudorza (Genuair) muscarinic Umeclidinium Incruse (Ellipta) antagonist) Formoterol Oxeze (Turbuhaler) Salmeterol Serevent (Diskus) Long-acting LABA Indacaterol Onbrez (Breezhaler) beta2 agonist Vilanterol (Ellipta) Olodaterol Striverdi (Respimat) Short-acting Salbutamol Ventolin (Diskus) SABA beta2 agonist Terbutaline Bricanyl (Turbuhaler) Short-acting SAMA Ipratropium Atrovent antimuscarinic 34 Treatments for COPD Abbreviation Full name Examples Brand (Device) Budesonide Pulmicort (Turbuhaler) Inhaled ICS Fluticasone Proprionate Flovent (Diskus) corticosteroid Fluticasone Furoate (Ellipta) Long-acting anticholinergic Tiotropium Spiriva (Respimat) LAMA (also known as Glycopyrronium Seebri (Breezhaler) LAAC long-acting Aclidinium Bromide Tudorza (Genuair) muscarinic Umeclidinium Incruse (Ellipta) antagonist) Formoterol Oxeze (Turbuhaler) Salmeterol Serevent (Diskus) Long-acting LABA Indacaterol Onbrez (Breezhaler) beta2 agonist Vilanterol (Ellipta) Olodaterol Striverdi (Respimat) Short-acting Salbutamol Ventolin (Diskus) SABA beta2 agonist Terbutaline Bricanyl (Turbuhaler) Short-acting SAMA Ipratropium Atrovent antimuscarinic 35 Treatments for COPD Abbreviation Full name Examples Brand (Device) Budesonide Pulmicort (Turbuhaler) Inhaled ICS Fluticasone Proprionate Flovent (Diskus) corticosteroid Fluticasone Furoate (Ellipta) Long-acting anticholinergic Tiotropium Spiriva (Respimat) LAMA (also known as Glycopyrronium Seebri (Breezhaler) LAAC long-acting Aclidinium Bromide Tudorza (Genuair) muscarinic Umeclidinium Incruse (Ellipta) antagonist) Formoterol Oxeze (Turbuhaler) Salmeterol Serevent (Diskus) Long-acting LABA Indacaterol Onbrez (Breezhaler) beta2 agonist Vilanterol (Ellipta) Olodaterol Striverdi (Respimat) Short-acting Salbutamol Ventolin (Diskus) SABA beta2 agonist Terbutaline Bricanyl (Turbuhaler) Short-acting SAMA Ipratropium Atrovent antimuscarinic 36 Treatments for COPD Abbreviation Full name Examples Brand (Device) Budesonide Pulmicort (Turbuhaler) Inhaled ICS Fluticasone Proprionate Flovent (Diskus) corticosteroid Fluticasone Furoate (Ellipta) Long-acting anticholinergic Tiotropium Spiriva (Respimat) LAMA (also known as Glycopyrronium Seebri (Breezhaler) LAAC long-acting Aclidinium Bromide Tudorza (Genuair) muscarinic Umeclidinium Incruse (Ellipta) antagonist) Formoterol Oxeze (Turbuhaler) Salmeterol Serevent (Diskus) Long-acting LABA Indacaterol Onbrez (Breezhaler) beta2 agonist Vilanterol (Ellipta) Olodaterol Striverdi (Respimat) Short-acting Salbutamol Ventolin (Diskus) SABA beta2 agonist Terbutaline Bricanyl (Turbuhaler) Short-acting SAMA Ipratropium Atrovent antimuscarinic 37 Treatments for COPD Abbreviation Full name Examples Brand (Device) Budesonide Pulmicort (Turbuhaler) Inhaled ICS Fluticasone Proprionate Flovent (Diskus) corticosteroid Fluticasone Furoate (Ellipta) Long-acting anticholinergic Tiotropium Spiriva (Respimat) LAMA (also known as Glycopyrronium Seebri (Breezhaler) LAAC long-acting Aclidinium Bromide Tudorza (Genuair) muscarinic Umeclidinium Incruse (Ellipta) antagonist) Formoterol Oxeze (Turbuhaler) Salmeterol Serevent (Diskus) Long-acting LABA Indacaterol Onbrez (Breezhaler) beta2 agonist Vilanterol (Ellipta) Olodaterol Striverdi (Respimat) Short-acting Salbutamol Ventolin (Diskus) SABA beta2 agonist Terbutaline Bricanyl (Turbuhaler) Short-acting SAMA Ipratropium Atrovent antimuscarinic 38 Treatments for COPD Abbreviation Full name Examples Brand (Device) Budesonide Pulmicort (Turbuhaler) Inhaled ICS Fluticasone Proprionate Flovent (Diskus) corticosteroid Fluticasone Furoate (Ellipta) Long-acting anticholinergic Tiotropium Spiriva (Respimat) LAMA (also known as Glycopyrronium Seebri (Breezhaler) LAAC long-acting Aclidinium Bromide Tudorza (Genuair) muscarinic Umeclidinium Incruse (Ellipta) antagonist) Formoterol Oxeze (Turbuhaler) Salmeterol Serevent (Diskus) DeviceLong-acting LABA Indacaterol Onbrez (Breezhaler) beta2 agonist Efficacy Vilanterol (Ellipta) Olodaterol Striverdi (Respimat) SafetyShort-acting Salbutamol Ventolin (Diskus) SABA beta2 agonist Terbutaline Bricanyl (Turbuhaler) Short-acting SAMA Ipratropium Atrovent antimuscarinic 39

1 Adapted from : Newman SP, et al. Lung Deposition of fenoterol and flunisolide delivered using a novel device for inhaled medicine: Comparison of Respimat with conventional metered- dose inhalers with and without spacer devices. Chest1998;113: 957-963. DPI (Diskus)

Slide the lever away from you as far as it will go

Breathe out until Place the mouthpiece in mouth and close lips firmly around it lungs are empty Breathe in as “fast” & as “hard” as you can until lungs are full Hold breath for 10s Breathe out

Adapted from asthmameds.ca 43 44 45 Respimat Turbuhaler Devices

Green & Go Red & Done

● Feedback on successful inhalation • Audible click when patient is inhaling sufficiently • Control window turns red when inhalation is complete

Tudorza® Genuair® Product Monograph, 2013 Treatments for COPD Abbreviation Full name Examples Brand (Device) Budesonide Pulmicort (Turbuhaler) Inhaled ICS Fluticasone Proprionate Flovent (Diskus) corticosteroid Fluticasone Furoate (Ellipta) Long-acting anticholinergic Tiotropium Spiriva (Respimat) LAMA (also known as Glycopyrronium Seebri (Breezhaler) LAAC long-acting Aclidinium Bromide Tudorza (Genuair) muscarinic Umeclidinium Incruse (Ellipta) antagonist) Formoterol Oxeze (Turbuhaler) Salmeterol Serevent (Diskus) DeviceLong-acting LABA Indacaterol Onbrez (Breezhaler) beta2 agonist Efficacy Vilanterol (Ellipta) Olodaterol Striverdi (Respimat) SafetyShort-acting Salbutamol Ventolin (Diskus) SABA beta2 agonist Terbutaline Bricanyl (Turbuhaler) Short-acting SAMA Ipratropium Atrovent antimuscarinic 49 LAS39: Change from baseline FEV1 by timepoint over 24 hours at Day 1

*p<0.05 aclidinium vs tiotropium This study alone does not constitute a head-to-head study to support comparative claims of aclidinium vs tiotropium. Beier et al. COPD 2013 Aclidinium reduces COPD exacerbation (any severity) rates (24 weeks): ATTAIN

1.6 Placebo 1.39 Aclidinium 400 µg BID

1.2 29% 0.98

p<0.05 0.8

(/pt/year) 0.60 33% COPD exacerbations 0.40 0.4 p<0.05

0.0 Healthcare Resource EXACT Utilization criteria criteria

Reproduced with permission Jones et al. CHEST 2012 Canadian RWE A retrospective observational propensity-matched cohort study Healthcare utilisation in the first year after initiating ICS/LABA therapy

Courses of oral steroids/year 0.66 0.79 0.85 (0.72, 1.00)

ED visits/year 0.16 0.23 0.75 (0.58, 0.97)

Hospital admissions/year 0.11 0.21 0.61 (0.47, 0.81) Addition of a tiotropium 1.63 2.01 0.71 (0.57, 0.89) prescription/year

In Canada, 5255 COPD patients were treated with an ICS/LABA before matching – 3969 (76%) patients in this cohort used FLU/SAL – 36% had exacerbations pre-index – More bud/form vs. flu/sal pats. had a first ICS/LABA initiated by a specialist (8% more) – Antibiotics were not evaluated as a definition of exacerbations – Patients were tracked for 1 year

Blais L et al. Clin Ther 2010; 32 (7): 1320 These slides have been supplied, on request, by AstraZeneca Scientific Affairs. For complete therapeutic and safety information please consult the SYMBICORT ® Product Monograph. COPD Exacerbations

BUD/FOR (n=2734) or FLU/SAL (n=2734)

Rate ratio (95% CI) 0.74 80 NNT = 3.4 (0.69, 0.79) All exacerbations ** 109

0.74 63 (0.68, 0.81) Oral steroids ** 85

38 0.70 Antibiotics ** (0.66, 0.75) 54 BUD/FOR SAL/FLU 15 0.71 Hospitalisations ** (0.65, 0.78) 21 NNT = 16

2.7 0.79 Emergency visits * (0.71, 0.89) 3.4

0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0 Event rate per 100 patient‐years Adjusted yearly rates of healthcare utilisation events were compared using Poisson regression analysis. **P<0.0001; *P=0.0003 for difference. CI, confidence intervals; BUD/FOR, budesonide/formoterol; FLU/SAL, fluticasone/salmeterol Larsson et al. J Intern Med 2013; DOI: 10.1111/joim.12067 These slides have been supplied, on request, by AstraZeneca Scientific Affairs. For complete therapeutic and safety information please consult the SYMBICORT ® Product Monograph. Treatments for COPD

Abbreviation Full name Examples Brand (Device) Budesonide Pulmicort (Turbuhaler) Inhaled ICS Fluticasone Proprionate Flovent (Diskus) corticosteroid Fluticasone Furoate (Ellipta) Long-acting anticholinergic Tiotropium Spiriva (Respimat) LAMA (also known as Glycopyrronium Seebri (Breezhaler) LAAC long-acting Aclidinium Bromide Tudorza (Genuair) muscarinic Umeclidinium Incruse (Ellipta) antagonist) Formoterol Oxeze (Turbuhaler) Long-acting Salmeterol Serevent (Diskus) LABA Device beta2 agonist Indacaterol Onbrez (Breezhaler) Efficacy Vilanterol (Ellipta) Short-acting Salbutamol Ventolin (Diskus) SABA Safety beta2 agonist Terbutaline Bricanyl (Turbuhaler) Short-acting SAMA Ipratropium Atrovent antimuscarinic 54 Pneumonia Risk in COPD Patients (Stratified by ICS Type)

Meta‐analysis of ICS use (studies 1‐3 yr duration)

Risk Ratio Corticosteroid Type HR (95%CI) Fluticasone (16 studies) 1.67 (1.47-1.89)* Budesonide (7 studies) 1.19 (0.92-1.53) [ns] Mometasone (1 study) 2.00 (0.83-4.81) [ns]

0.1 0.2 0.5 1 2 5 10 Corticosteroid Safer Corticosteroid Harmful

*statistically significant increase with fluticasone p<0.0001 [ns] = no statistically significant increase in risk detected • The elderly and those with more severe disease and lower FEV1s are at the highest risk of pneumonia.

Singh S, Loke YJ. Curr Opin Pulm Med. 2010; 16: 118‐122. Cumulative Pneumonia Rate vs Time Post Index

Fluticasone/salmeterol group Budesonide/formoterol group Any pneumonia Any pneumonia Hospitalised pneumonia Hospitalised pneumonia

110 100 All pneumonias 90 RR 1.73 (1,57; 1.90) P<0.001 NNT 23 80 70 60 Hospitalised pneumonias 50 RR 1.74 (1,56; 1.94) P<0.001 NNT 34 40 30 20 10 0 0123456789

Cumulative rate pneumonia per 100 patients Years Adjusted yearly pneumonia event rates compared using Poisson regression analysis. Janson et al. BMJ 2013;346:f3306 DOI: 10.1136/bmj.f3306

These slides have been supplied, on request, by AstraZeneca Scientific Affairs. For complete therapeutic and safety information please consult the SYMBICORT ® Product Monograph. An Immunosuppressant / Infection hypothesis

Fluticasone /salmeterol

ASL

Mucosa/Lung tissue

ASL = Airway surface liquid Bacteria Budesonide Fluticasone Budesonide/GCS-receptor Fluticasone/GCS-receptor

1. Wedzicha JA et al. AJRCCM 2008 2. Calverley et al. Chest 2011;139:505 3. Patterson C et al Respiratory Research 2012,13:40 4. Ek A et al Allergy (1999). 54: 691 5. Miller-Larsson et al. AJRCCM (2000). 162: 145 6. Johnsson M et al Allergy (1995) 50:s11-14 7. Dalby C, et al. Respir Res (2009); 10:104

Flunisolide 140 <2 min

Triamcinolone 21 n.d. acetonide Budesonide 16 6 min

Beclomethasone 16 n.d. 17-propionate Fluticasone 0.16 >8h 17-propionate Beclomethasone 0.13 >5h dipropionate

Högger and Rohdewald, Rev Contemp Pharm 1998 n.d.= no data

Flunisolide 140 <2 min

Triamcinolone 21 n.d. acetonide Budesonide 16 6 min

Beclomethasone 16 n.d. 17-propionate Fluticasone 0.16 >8h 17-propionate Beclomethasone 0.13 >5h dipropionate

Högger and Rohdewald, Rev Contemp Pharm 1998 n.d.= no data

Gavaldà et al. 2014 Two major acid and alcohol metabolites are inactive Sentellas et al, 2010 Alberti et al, 2010 ICS + LABA – Advair (Diskus)

Abbreviation Full name Examples Brand Budesonide Pulmicort (Turbuhaler) Inhaled ICS Fluticasone Proprionate Flovent (Diskus) corticosteroid Fluticasone Furoate (Ellipta) Long-acting anticholinergic Tiotropium Spiriva (Respimat) LAMA (also known as Glycopyrronium Seebri (Breezhaler) LAAC long-acting Aclidinium Bromide Tudorza (Genuair) muscarinic Umeclidinium Incruse (Ellipta) antagonist) Formoterol Oxeze (Turbuhaler) Long-acting Salmeterol Serevent (Diskus) LABA beta2 agonist Indacaterol Onbrez (Breezhaler) Vilanterol (Ellipta) Short-acting Salbutamol Ventolin (Diskus) SABA beta2 agonist Terbutaline Bricanyl (Turbuhaler) Short-acting SAMA Ipratropium Atrovent antimuscarinic 65 LAMA + LABA – Stiolto Respimat Abbreviation Full name Examples Brand Budesonide Pulmicort (Turbuhaler) Inhaled ICS Fluticasone Proprionate Flovent (Diskus) corticosteroid Fluticasone Furoate (Ellipta) Long-acting anticholinergic Tiotropium Spiriva (Respimat) LAMA (also known as Glycopyrronium Seebri (Breezhaler) LAAC long-acting Aclidinium Bromide Tudorza (Genuair) muscarinic Umeclidinium Incruse (Ellipta) antagonist) Formoterol Oxeze (Turbuhaler) Salmeterol Serevent (Diskus) Long-acting LABA Indacaterol Onbrez (Breezhaler) beta2 agonist Vilanterol (Ellipta) Olodaterol Striverdi (Respimat) Short-acting Salbutamol Ventolin (Diskus) SABA beta2 agonist Terbutaline Bricanyl (Turbuhaler) Short-acting SAMA Ipratropium Atrovent antimuscarinic 66 LAMA + LABA – Duaklir (Genuair)

Abbreviation Full name Examples Brand (Device) Budesonide Pulmicort (Turbuhaler) Inhaled ICS Fluticasone Proprionate Flovent (Diskus) corticosteroid Fluticasone Furoate (Ellipta) Long-acting anticholinergic Tiotropium Spiriva (Respimat) LAMA (also known as Glycopyrronium Seebri (Breezhaler) LAAC long-acting Aclidinium Bromide Tudorza (Genuair) muscarinicDevice Umeclidinium Incruse (Ellipta) antagonist) Formoterol Oxeze (Turbuhaler) Long-actingEfficacy Salmeterol Serevent (Diskus) LABA beta2 agonist Indacaterol Onbrez (Breezhaler) Vilanterol (Ellipta) Short-actingSafety Salbutamol Ventolin (Diskus) SABA beta2 agonist Terbutaline Bricanyl (Turbuhaler) Short-acting SAMA Ipratropium Atrovent antimuscarinic 68 COPD Risk & Smoking Cessation1,5,7

Never smoked or not susceptible to smoke 25)

Smoked regularly Stopped smoking

age at 45 (mild COPD) and susceptible to

at effects of smoke value of

Stopped smoking Disability at 65 (severe COPD) (% 1 FEV Death

Age (years) Fletcher C et al. Br Med J. 1977;1:1645–1648. Peter Lin MD CCFP COPDDirector Primary CareMaze Initiatives Canadian Heart Research Centre

Keep COPD in DDx Tools for Assessing Risk Medications: Bronchodilators vs ICS Step up: Single then dual then triple Rx Decide based on: Device, Efficacy, Safety Avoid Exacerbations