New and Emerging Therapies for Asthma and COPD

Edward Omron MD, MPH, FCCPPulmonary and Critical Care MedicineSaint Louise Regional Medical Center

What is Asthma?

• Reversible lung disease• The airways of the lung are inflamed, swollen and

narrowed resulting in “wheezing”• Breathing problems occur in “attacks” but the

disease is continuous • Recurrent cough, chest tightness / pain, or shortness

of breath• Symptoms worsen with exercise, infection, changes

in weather, or at night.

Asthma Airways

Asthma Facts

• In 2009, 25 million Americans had asthma– Of these 13 million have had an asthma attack

• In 2007 there were 3500 deaths from asthma– 63% of these deaths occurred in women

• The prevalence of adult asthma in CA 2009 is 8%• Asthma accounts for 50 billion health care dollars

yearly

Types of Asthma

Mainstays of Therapy

Inhaled Corticosteroids Remain the MAINSTAY of treatment in all asthmatic groups

Advances in Therapy

• There is no cure of asthma thus far in 2012• CONFIRM the diagnosis before any

augmentation of treatment of regimens– Rule out for example vocal cord dysfunction– Interstitial Lung Disease

• Severe persistent asthma is a great challenge to both the patient and the physician

Xolair (Omalizumab)• Severe persistent asthmatics with allergies and an

elevated IgE antibody level• IgE is an allergy antibody– It binds to allergens and causes the release of

inflammatory mediators which makes asthma worse

• Xolair binds to IgE antibody and turns it off• Reduced medication use, symptoms, and improved

quality of life • Cost about $1500.00 monthly• Monthly subcutaneous injections

Xolair and IgE

Bronchial Thermoplasty (BT)

• Severe asthmatics have excessive smooth muscle in the airways

• BT is a non-drug procedure that reduces airway smooth muscle by applying heat to the airways– This reduces the frequency of asthma attacks

• Three outpatient procedures performed three weeks apart under sedation

• Benefits:– 32% reduction in asthma attacks– 84% reduction in ER visits– Improved asthma quality of life

Airway Lumen in Severe Asthma

Bronchial Thermoplasty

What is COPD?

• Two irreversible lung diseases that frequently coexist together:– Chronic bronchitis: airways of the lung are inflamed,

swollen and narrowed resulting in “wheezing”• HEAVY mucus or phlegm is coughed up• Breeding ground for recurrent infections

– Emphysema: the scaffolding of the lung is destroyed resulting in multiple “holes”

• Progressive Shortness of Breath associated with chest pressure and exercise limitation

COPD Forms

Bronchitic Emphysematous

COPD Pathology

COPD (Chronic Obstructive Lung Disease)

COPD Facts

• Third leading cause of death in America– 125,000 lives in 2007

• Smoking is the primary risk factor for COPD• Female smokers are 13 times more likely to die from

COPD than females who never smoked• 13 million adults were estimated to have COPD in

2008• 50 Billion in health care costs yearly

COPD CHEST XRAY

COPD/Emphysema CT CHEST

Diagnosis of COPD

• Pulmonary Physician• Appropriate Symptoms• Diagnostic Studies– Chest X-Ray and CT CHEST– Pulmonary Function Study– 6 minute walk test– Arterial Blood Gas– Alpha 1 antitrypsin deficiency

COPD Mimics

• Congestive Heart Failure• Asthma• Bronchiectasis• Interstitial Lung Disease

Pharmacology

• Bronchodilators– B Agonists– Anticholinergics– Xanthines

• Steroids (intravenous inpatient and inhaled outpatient)• Vaccines(influenza and pneumococcus)• Antibiotics• Oxygen• Mucolytics and Flutter/Acapella Valves• Pulmonary rehabilitation

Pulmonary Rehabilitation

What effect does COPD have on my ability to be active?

• Shortness of breath = inactivity• Muscle Weakness = Fatigue• Loss of independence = depression• Isolation• Weight Gain• Immune system weakens

Why should I exercise for COPD?

• Builds Strength• Less shortness of breath• More independence• Greater reserve to fight infection• Less fatigue• Weight control• Quality of life

How do I exercise for COPD?

• Under care of a health professional• Physical Therapist guides training• Stretches• Aerobic Conditioning• How to cough, breath, and train safely

Diaphragmatic Breathing

Elbow Breathing

Pursed Lip Breathing

Pursed Lip Breathing

Advances in Therapy• Indacaterol (Arcapta Neohaler)– Once daily long acting (24 hours) bronchodilator in COPD– Rapid onset with intense bronchodilation– Improvement in shortness of breath, exercise

performance, and quality of life.– Hopefully available later this year, excellent safety profile

Roflumilast (Daliresp)

• Phosphodiesterase inhibitors (similar to caffeine)• Decreases airway inflammation• Not a bronchodilator• Side effects: Headache, Nausea, Diarrhea• Reduces COPD exacerbations• Once daily oral dosing, cannot be used in liver

dysfunction

Alpha-1 Antitrypsin Deficiency

• A genetic condition associated with early onset COPD and liver disease

• Alpha 1-Antitrypsin is a enzyme that protects the lung from enzymes that break down lung tissue

• About 1-3% of patients with COPD are predicted to have alpha1-antitrypsin deficiency.

• Intravenous (IV) augmentation therapy with alpha1-antitrypsin benefits some patients

• Identified in all populations• All COPD patients are now screened for this disorder

Stem Cells in COPD

• Stem cells are derived from the bone marrow– Can regenerate normal lung tissue with manipulation– Several studies in animal models show great promise in

COPD– Too early to comment

• Vitamin D– Early enthusiasm – Most recent study in severe COPD disappointing– No consensus

Resources

• American Lung Association– http://www.lung.org/lung-disease/

• http://www.onebreath.org/• http://www.thoracic.org/education/breathing

-in-america/index.php