World COPD Day C hronic O bstructive P ulmonary D isease Press Conference Kyoto, Japan November 19, 2006

1. World COPD Day Chronic Obstructive Pulmonary Disease Press Conference Kyoto, Japan November 19, 2006

2. Opening Remarks Yoshinosuke Fukuchi, MD, PhD Introduction of GOLD Sonia Buist, MD New GOLD Guidelines Suzanne Hurd, PhD Klaus F. Rabe, MD, PhD Additional Comments Peter Calverley, MD Comments from WONCA Chris van Weel, MD Closing Remarks Claude Lenfant, MD World COPD Day Press Conference

3. Definition of COPD • Chronic Obstructive Pulmonary Disease is a preventable and treatable disease with some significant extrapulmonary effects. • The pulmonary component is characterized by airflow limitation that is not fully reversible. Healthy Alveolus COPD

4. Chronic Obstructive Pulmonary Disease (COPD) • The airflow limitation in COPDis usually progressive and associated with an abnormal inflammatory response of the lungs to noxious particles and gases • Severe COPD leads to respiratory failure, hospitalization and eventually death from suffocation

5. Risk Factors for COPD Nutrition Infections Socio-economic status Aging Populations

6. Dr. A. Sonia BuistIntroduction of GOLD Chair, GOLD Executive Committee Portland, Oregon USA

7. lobal Initiative for Chronicbstructiveungisease GOLD November 19, 2006 World COPD Day, Kyoto Japan

8. Why was GOLD Started? • The social and economic burden of COPD is increasing rapidly in countries at all levels of economic development • COPD is under-appreciated, under-diagnosed and under-treated • Important questions about COPD are still unanswered

9. COPD is Under-appreciated and Under-diagnosed Example from Japan: • NICE Survey of COPD prevalence • Carried out in several regions of Japan using standardized methods

10. COPD Prevalence Rate (adjusted)* in Population  40 years 8.5%** 0.3% Study MHW Survey 5.3 vs 0.2M COPD patients in Japan ≥40 years *Adjusted for age, sex, cluster **8.5-10.9% depending on criteria Fukuchi et al. Respirology 2004;9:458-65

11. COPD Prevalence Survey (NICE) in Japan Had prior diagnosis Did not have prior diagnosis: Fukuchi et al. Respirology 2004;9:458-65

12. Prevalence of GOLD Stage 1+ COPD1, Guangzhou, China MEN 15.3% WOMEN 7.6% 1 FEV1/FVC<0.70, post BD

13. Of the six leading causes of death in the United States, only COPD has been increasing steadily since 1970. Source: Jemal A. et al. JAMA 2005

14. COPD Mortality by Gender,U.S., 1980-2000 Number Deaths x 1000

15. COPD Mortality Worldwide 19902020 Ischaemic heart disease Cerebrovascular disease Lower resp infection Diarrhoeal disease Perinatal disorders COPD Tuberculosis Measles Road Traffic Accidents Lung Cancer 3rd 6th Stomach Cancer HIV Suicide Source: Murray & Lopez. Lancet 1997

16. Why is COPD Increasing Worldwide? • Increase in exposure to risk factors (especially tobacco) in developing countries & in women • Changing demographics globally with more of the population, especially in the developing countries living into the COPD age range

17. Dr. Suzanne S. HurdNew GOLD Guidelines GOLD Scientific Director Gaithersburg, Maryland, USA

18. GOLD Objectives • Increase awareness of COPD among health professionals, health authorities, and the general public • Improve diagnosis, management and prevention of COPD • Stimulate research in COPD

19. Revised 2006 Global Strategy for Diagnosis, Management and Prevention of COPD • Definition, Classification • Burden of COPD • Risk factors • Pathogenesis, pathology, pathophysiology • Management • Practical Considerations

20. Revised 2006 MAJOR CHANGES Global Strategy for Diagnosis, Management and Prevention of COPD Revised 2006

21. Dr. Klaus RabeNew GOLD Guidelines Chair, GOLD Science Committee Leiden, The Netherlands

22. Revised 2006 Global Strategy for Diagnosis, Management and Prevention of COPD • Definition, Classification • Burden of COPD • Risk factors • Pathogenesis, pathology, pathophysiology • Management • Practical Considerations

23. Definition of COPD • Chronic Obstructive Pulmonary Disease (COPD) is a preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients. • Its pulmonary component is characterized by airflow limitation that is not fully reversible. • The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases.

24. Diagnosis of COPD EXPOSURE TO RISK FACTORS SYMPTOMS cough tobacco sputum occupation shortness of breath indoor/outdoor pollution è SPIROMETRY

25. Spirometry for COPD Diagnosis and Classification of Severity

26. Classification of COPD Severity by Spirometry Stage I: Mild FEV1/FVC < 0.70 FEV1> 80% predicted Stage II: Moderate FEV1/FVC < 0.70 50% < FEV1 < 80% predicted Stage III: Severe FEV1/FVC < 0.70 30% < FEV1 < 50% predicted Stage IV: Very Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus chronic respiratory failure

27. COPD and Co-Morbidities • COPD has significant extrapulmonary (systemic) effects • Weight loss, nutritional abnormalities • Skeletal muscle dysfunction

28. COPD and Co-Morbidities • COPD patients are at increased risk: • Myocardial infarction, angina • Osteoporosis • Respiratory infection • Depression • Diabetes • COPD and lung cancer

29. Dr. Peter Calverley New GOLD Guidelines GOLD Executive/Science Committee Liverpool, England

30. Revised 2006 Global Strategy for Diagnosis, Management and Prevention of COPD • Definition, Classification • Burden of COPD • Risk factors • Pathogenesis, pathology, pathophysiology • Management • Practical Considerations

31. Four Components of Care • Assess and Monitor Disease • Reduce Risk Factors • Manage Stable COPD • Manage Exacerbations

32. GOALS of COPD MANAGEMENT VARYING EMPHASIS WITH DIFFERING SEVERITY • Relieve symptoms • Prevent disease progression • • Improve exercise tolerance • • Improve health status • • Prevent and treat complications • • Prevent and treat exacerbations • • Reduce mortality

33. DIAGNOSIS AND RISK FACTORS • Bronchodilator testing no longer mandatory • Post-bd FEV1 still the preferred outcome • Symptom assessment, e.g., MRC dyspnoea • Co-morbid pathology to be documented • New therapy for smoking cessation • More emphasis on indoor pollution

34. Active reduction of risk factor(s); influenza vaccination Addshort-acting bronchodilator (when needed) I: Mild II: Moderate III: Severe IV: Very Severe Addregular treatment with one or more long-acting bronchodilators (when needed); Addrehabilitation Addinhaled glucocorticosteroids if repeated exacerbations Addlong term oxygenif chronic respiratory failure. Considersurgical treatments

35. OTHER TREATMENT OPTIONS • Less support for mucolytic and antioxidant therapy • Pneumococcal vaccination • Rehabilitation remains a key intervention • Oxygen therapy reviewed • Surgery and COPD guidance

36. COPD EXACERBATIONS • COPD exacerbations defined: “An event in the natural course of the disease characterized by a change in the patient’s baseline dyspnea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.” • Antibiotics with specific advice • NIV explained and prioritised • Care at home/follow up

37. Dr. Chris van WeelComments from WONCA GOLD Executive Committee President, World Organization of Family Physicians Nijmegen, The Netherlands

38. Revised 2006 Global Strategy for Diagnosis, Management and Prevention of COPD • Definition, Classification • Burden of COPD • Risk factors • Pathogenesis, pathology, pathophysiology • Management • Practical Considerations

39. COPD Comorbidities • Comorbid heterogeneity • Common cause • Heart failure • Lung cancer • Complicating • Pneumonia • Coincidential • Diabetes mellitus • Arthritis hip/knee • Depression

40. COPD – The Disease Airflow obstruction Function decline Continuous treatment Lifestyle Regular follow-up ‘Management plan’ Compliance Effects, safety treatment PATIENT – DISEASE ANOMALY Patient with COPD • Social isolation • Unhealthy environment • Poverty • Poor self-efficacy • Multiple health problems • Disruptive life conditions • Trust & support • Safety line

41. VERTICAL vs HORIZONTAL PROGRAMS OF CARE HIV AIDS MALARIA TB COPD INTEGRATED PRIMARY CARE

42. Practical Considerations: Conclusions • Link science to money • Organize special programs through primary care: Ten for 2010 • Make a portion (10%) of special program money available for primary care development

43. Dr. Claude LenfantClosing Comments GOLD Executive Director Gaithersburg, Maryland, US

44. COPD: An Increasing Public Health Problem Worldwide • COPD is increasing in prevalence in many countries of the world • COPD is treatable and preventable • The GOLD program offers a strategy to identify patients and to treat them according to the best medications available

45. COPD: An Increasing Public Health Problem Worldwide • COPD can be prevented by avoidance of risk factors, the most notable being tobacco smoke • Patients with COPD have multiple other conditions (comorbidities) that must be taken into consideration • GOLD has developed a global network to raise awareness of COPD and disseminate information on diagnosis and treatment

46. Bangladesh Saudi Arabia Slovenia Germany Ireland Yugoslavia Australia Croatia Turkey Canada Brazil Austria Taiwan ROC United States Portugal Thailand Malta Norway Mexico Moldova Greece China Guatemala South Africa United Kingdom Hong Kong China New Zealand Italy Tatarstan Republic Argentina France Nepal Chile United Arab Emirates Japan Peru Poland Korea Egypt Netherlands Latvia Costa Rica Venezuela Russia Republic of Georgia Switzerland Macedonia Iceland Canada Denmark Lithuania Belgium Slovakia Singapore Romania Spain Ukraine Columbia India Sweden Vietnam Kyrgyzstan Albania

47. World Health Organization - Global Alliance Against Chronic Respiratory Diseases - GARD

48. World COPD Day Chronic Obstructive Pulmonary Disease Press Conference Kyoto, Japan November 19, 2006