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NICE COPD guidance will prompt 'major shift in GP thinking'

By Lilian Anekwe

New NICE guidance on the diagnosis and management of COPD will encourage a ‘major shift in thinking' amongst GPs, according to a GP who helped write the guidance.

The recommendations in the final version, published today, includes new recommendation on the sequencing and combination of inhaled therapies, as well as diagnostic spirometry and clinical assessment (see box).

GPs must confirm a diagnosis of COPD with post-bronchodilator spirometry, and the NICE grading of COPD, into patients with mild, moderate, severe and very severe disease, has been updated to bring it into line with the GOLD classification system.

GPs should offer suitable patients nicotine replacement therapy, and the guidance also recommends pulmonary rehabilitation should be made available to patients who have recently been in hospital for an acute exacerbation.

Pulse reported in November last year that the draft guidance, intended to update the 2004 guidelines, relaxed the threshold at which treatment should be initiated and could lead to many more patients being treated.

Dr Kevin Gruffyd-Jones, a GPSI in respiratory disease in Box, Wiltshire and a member of the COPD guideline development committee said GPs may find the new treatment algorithm, which has been boosted to reflect the results of major trials including TORCH and UPLIFT, ‘more complicated'.

‘It might confuse people initially. GPs should now include people with a post-bronchodilator FEV1/FVC of less than 0.7 and FEV1 of more than 80% predicted for treatment.

‘The implication is that we could be treating a heck of a lot more people, especially now that we are being encourage by the national strategy to screen for the "missing millions". The potential is there to increase the number of people diagnosed but the important caveat is that patients who fit into that category must also have additional symptoms present.'

But he insisted COPD patients would benefit from the changes.

‘This guidance really is a major shift in thinking because it encourages GPs to move away from thinking COPD is just a disease of the lung and to take a more holistic approach to the diagnosis, grading and management of COPD.

‘There's much greater emphasis on other issues, aside from lung function and airflow limitation, in grading disease severity. It fundamentally alters the way we give inhaled drugs, while also placing much more emphasis on non-pharmacological management.'

Key recommendations

• In people with stable COPD who remain breathless or have exacerbations despite use of short-acting bronchodilators as required, offer the following as maintenance therapy:
- if FEV1 ≥ 50% predicted: either long-acting beta2 agonist (LABA) or long-acting muscarinic antagonist (LAMA)
- if FEV1 < 50%="" predicted:="" either="" laba="" with="" an="" inhaled="" corticosteroid="" (ics)="" in="" a="" combination="" inhaler,="" or="" lama.="">
• Offer LAMA in addition to LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking LABA+ICS, irrespective of their FEV1.

Consider alternative diagnoses or investigations in:
• Older people without typical symptoms of COPD where the FEV1/FVC ratio is <>
• Younger people with symptoms of COPD where the FEV1/FVC ratio is ≥ 0.7

NICE clinical guideline 101 – Chronic obstructive pulmonary disease The new guidance clarifies the use of inhaled therapies

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