Prevention of COPD exacerbations: a’European Respiratory ...

1 Prevention of COPD exacerbations: a European Respiratory Society/American Thoracic Society guidelineJadwiga A. Wedzicha (ERS co-chair)1, Peter Calverley2, Richard K. Albert3,Antonio Anzueto4, Gerard J. Criner5, John R. Hurst6, Marc Miravitlles7,Alberto Papi8, Klaus F. Rabe9, David Rigau10, Pawel Sliwinski11,Thomy Tonia12, J rgen Vestbo13, Kevin C. Wilson14and Jerry A. Krishnan(ATS co-chair)15 Affiliations:1 Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, of Ageing and Chronic Disease, University of Liverpool, Liverpool, of Medicine,University of Colorado, Denver, Aurora, CO, of Texas Health Science Center and South TexasVeterans Health Care System, San Antonio, TX, of Thoracic Medicine and Surgery, Lewis KatzSchool of Medicine at Temple University, Philadelphia, PA, Respiratory , University College London,London, Dept, Hospital Universitari Vall d Hebron, CIBER de Enfermedades Respiratorias(CIBERES)

2 , Barcelona, Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, of Internal Medicine, Christian-Albrechts University, Kiel and LungenClinic Grosshansdorf, AirwayResearch Centre North, German Centre for Lung Research, Grosshansdorf, Center, Barcelona, Dept of Respiratory Medicine, Institute of Tuberculosis and LungDiseases, Warsaw, of Social and Preventive Medicine, University of Bern, Bern, of Infection, Immunity and Respiratory Medicine, University of Manchester,Manchester, of Medicine, Boston University School of Medicine, Boston, MA, ofIllinois Hospital and Health Sciences System, Chicago, IL, : Marc Miravitlles, Pneumology Dept, Hospital Universitari Vall d Hebron, Pg. Vall d Hebron119 129, Barcelona 08035, Spain. E-mail: @ERSpublicationsDifferent strategies are useful for the Prevention of COPD this article as:Wedzicha JA, Calverley PMA, Albert RK,et al.

3 Prevention of COPD exacerbations: a European Respiratory Society/American Thoracic Society Respir J2017; 50: 1602265[ ].ABSTRACTThis document provides clinical recommendations for the Prevention of chronic obstructivepulmonary disease (COPD) exacerbations. It represents a collaborative effort between the EuropeanRespiratory Society and the American Thoracic evidence syntheses were performed to summarise all available evidence relevant to the TaskForce s questions. The evidence was appraised using the Grading of Recommendations, Assessment,Development and Evaluation approach and the results were summarised in evidence profiles. The evidencesyntheses were discussed and recommendations formulated by a multidisciplinary Task Force of COPD considering the balance of desirable (benefits) and undesirable consequences (burden in the form ofadverse effects and cost), quality of evidence, feasibility, and acceptability of various interventions, the TaskForce made recommendations for mucolytic, long-acting muscarinic antagonist, phosphodiesterase-4 inhibitor(roflumilast) and macrolide therapy, as well as a conditional recommendation against fluoroquinolonetherapy.

4 All of the recommendations were conditional, except for a strong recommendation for the use of along-acting antimuscarinic agentversusa long-acting 2-adrenergic, indicating that there was uncertaintyabout the balance of desirable and undesirable consequences of the intervention, and that well-informedpatients may make different choices regarding whether to have or not have the specific guideline summarises the evidence and provides recommendations for pharmacological therapy forthe Prevention of COPD ERS 2017 Respir J 2017; 50: 1602265 TASK FORCE REPORTERS/ATS GUIDELINESI ntroductionPrevention of exacerbations is a key objective in chronic obstructive pulmonary disease (COPD)management. There are patients with COPD that are prone to suffer from recurrent exacerbations [1] andthey experience a more severe impairment in health status [2, 3].

5 Moreover, patients with recurrenthospitalisations for exacerbations have a reduced survival [4]. Although no definitive evidence exists aboutthe impact of Prevention of exacerbations of COPD in reducing mortality, treatments that effectivelyreduce the frequency and/or severity of exacerbations may have an impact on quality of life, theprogression and ultimately the prognosis of guideline was a collaborative effort between the European Respiratory Society (ERS) and theAmerican Thoracic Society (ATS). It employed a systematic review of the literature followed by theGrading of Recommendations Assessment, Development and Evaluation (GRADE) [5] approach todevelop recommendations that answer the following five questions:1) Should mucolytics be prescribed to patients with stable COPD to prevent COPD exacerbations?

6 2) Are long-acting -agonists (LABAs) or long-acting muscarinic antagonists (LAMAs) preferable inpatients with stable COPD to prevent COPD exacerbations?3) Should roflumilast be prescribed to patients with COPD associated with chronic bronchitis andexacerbations to prevent subsequent exacerbations?4) Should fluoroquinolones be prescribed to patients with stable COPD to prevent COPD exacerbations?5) Should macrolides be prescribed to patients with stable COPD to prevent COPD exacerbations?This ERS/ATS guideline focuses on the Prevention of COPD exacerbations. A separate ERS/ATS guidelinewas recently published that addresses the management of COPD exacerbations [6]. We accepted otherevidence-based evaluations of certain established therapies and did not seek to repeat the analyses alreadyundertaken.

7 Our role is to update and address gaps in the existing evidence. Other therapies are effectiveand might be preferred to those we address here, cessation or dual bronchodilator therapy,which were not considered within the time frame of this Task methodology followed for the development of this document regarding formulation of questions,rating the important outcomes, study selection, evidence synthesis, and formulating and grading theevidence has been described in detail in the previous ERS/ATS guideline on management of COPD exacerbations [6], and can also be found in the supplementary material. Some important aspects of themethodology are summarised in the following compositionThe Task Force co-chairs ( Wedzicha and Krishnan) were selected by the ERS and ATS.

8 They ledall aspects of project management and selected the panellists, which included 11 clinicians with experiencein COPD management and research. In addition, there were two methodologists (T. Tonia and D. Rigau)and a clinician-methodologist ( Wilson). The lead methodologist (T. Tonia) identified and collectedthe evidence, performed the evidence syntheses, constructed the evidence profiles, and ensured that all themethodological requirements were met, with assistance from the other methodologists. Thresholds forclinically important differences between treatment groups (used to judge imprecision) included thefollowing relative risk reductions: mortality 15%, exacerbations 20%, hospitalisations 20% and adverseThis article has supplementary material available from : Nov 16 2016 | Accepted after revision: May 12 2017 The guidelines published by the European Respiratory Society (ERS) incorporate data obtained from a comprehensiveand systematic literature review of the most recent studies available at the time.

9 Health professionals are encouraged totake the guidelines into account in their clinical practice. However, the recommendations issued by this guideline maynot be appropriate for use in all situations. It is the individual responsibility of health professionals to consult othersources of relevant information, to make appropriate and accurate decisions in consideration of each patient s healthcondition and in consultation with that patient and the patient s caregiver where appropriate and/or necessary, and toverify rules and regulations applicable to drugs and devices at the time of document was endorsed by the ERS Executive Committee in June 2017 and approved by the ATS Board ofDirectors in May of interest: D. Rigau and T. Tonia act as methodologists for the European Respiratory Society.

10 All other disclosurescan be found alongside this article at GUIDELINES | WEDZICHA ET 15%. They also included the following absolute reduction: St George s Respiratory Questionnairescore change of 4 co-chairs and panellists discussed the evidence and formulated the recommendations; themethodologists did not participate in the development of recommendations. All panel members wererequired to disclose their conflicts of interest. Being an author of a publication reporting the effect of anintervention in Prevention of exacerbations was considered as a conflict of interest. At least 50% of theco-chairs and 50% of the panel were required to be free from conflicts of interest. Individuals withpotential conflicts of interest took part in the discussions about the evidence but did not participate in theformulation of searchesOur literature searches used the National Institute of Health and Clinical Excellence (NICE) guidelines asa starting point [7].