Introduction

Introduction

Chronic obstructive pulmonary disease (COPD) is characterised by airflow obstruction that is usually progressive and not fully reversible; it is predominantly caused by smoking[1]. COPD is a common cause of death and long-term disability. According to GP registers, there were nearly 900,000 patients with COPD in England in 2010/11[2]. During the same period there were approximately 120,000 hospital admissions in England in which COPD was the primary diagnosis[3].

The NICE clinical guideline on COPD defines COPD as follows:

  • Airflow obstruction is defined as a reduced FEV1/FVC ratio (where FEV1 is forced expired volume in 1 second and FVC is forced vital capacity), such that FEV1/FVC is less than 0.7.

  • If FEV1 is at least 80% predicted normal, a diagnosis of COPD should only be made in the presence of respiratory symptoms, for example breathlessness or cough.

Classification of severity of airflow obstruction in COPD according to NICE guidance is shown in table 1.

Table 1 Classification of severity of airflow obstruction in COPD

Severity of airflow obstruction

Post-bronchodilator FEV 1 /FVC

FEV 1 % predicted

Post-bronchodilator

<0.7

≥80%

Stage 1: Milda

<0.7

50–79%

Stage 2: Moderate

<0.7

30–49%

Stage 3: Severe

<0.7

<30%

Stage 4: Very severeb

Abbreviations: COPD, chronic obstructive pulmonary disease; FEV1, forced expired volume in 1 second; FVC, forced vital capacity.

a Symptoms should be present to diagnose COPD in people with mild airflow obstruction.

b Or FEV1 <50% with respiratory failure.

The NICE clinical guideline on COPD advises that all patients who are still smoking should be encouraged to stop, and offered help to do so, at every opportunity. The guideline recommends the following inhaled treatments for managing people with stable COPD. The list is not comprehensive but does include the key recommendations that relate to this evidence summary and the likely place in therapy of glycopyrronium bromide.

  • Short-acting bronchodilators, as necessary, should be the initial empirical treatment for the relief of breathlessness and exercise limitation.

  • In people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as required, offer the following as maintenance therapy:

    • if FEV1 is at least 50% predicted: either long-acting beta2 agonist (LABA) or long-acting muscarinic antagonist (LAMA)

    • if FEV1 is less than 50% predicted: either LABA with an inhaled corticosteroid (ICS) in a combination inhaler, or LAMA.

  • In people with stable COPD and an FEV1 of at least 50% who remain breathless or have exacerbations despite maintenance therapy with a LABA:

    • consider LABA+ICS in a combination inhaler

    • consider LAMA in addition to LABA where ICS is declined or not tolerated.

  • 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 LABA+ICS in a combination inhaler in addition to LAMA for people with stable COPD who remain breathless or have exacerbations despite maintenance therapy with LAMA irrespective of their FEV1.

  • The choice of drug(s) should take into account the person's symptomatic response and preference, and the drug's potential to reduce exacerbations, its side effects and cost.

See the NICE pathway on COPD for more information.



[2] NHS Information Centre (2011) QOF prevalence data tables 2010/11