从GOLD更新看支舒剂在COPD治疗中的基石作用洛阳.ppt

慢阻肺合并症 胃食管返流被认为与慢阻肺急性加重风险增加有关 首次提到胃食管返流与慢阻肺患者急性加重风险增加及健康状态下降相关(P48) Gastroesophageal reflux disease (GERD) is an independent risk factor for exacerbations and is associated with worse health status. The mechanisms by which GERD influences exacerbations are yet to be understood and the optimal treatment strategy to manage comorbidity COPD/GERD has not been established.1 1.Martinez CH, et al; COPD Gene Investigators. Impact of self-reported gastroesophageal reflux disease in subjects from COPD Gene cohort. Respir Res 2014; 15: 62. 认知功能障碍为慢阻肺合并症之一 提出轻度认知障碍与慢阻肺相关(P51) COPD significantly increases the risk of developing mild cognitive impairment 1. Impaired cognitive function is acknowledged as a feature of COPD 2 and while there is no current evidence of treatment providing benefit, patients who have evidence of mild cognitive impairment should be managed in a similar way to patients with primary dementia. 1.Singh B, et al. A prospective study of chronic obstructive pulmonary disease and the risk for mild cognitive impairment. JAMA Neurol 2014; 71: 581–588. 2.Dodd JW, et al. Cognitive function in COPD. Eur Respir J 2010; 35: 913–922. 慢阻肺合并症 附 录 章 节 ACOS 单独作为附录，内容与GINA2014一致 主 要 内 容 1. 2015GOLD的主要更新内容 2. ICS在慢阻肺治疗中的地位 3. 支气管舒张剂是慢阻肺治疗的基石 1.Barnes PJ Br J Pharmacol 2006; 148:245-54; Barnes PJ Chest 2006; 129:151-5 2.Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Revised 2014. 慢阻肺的炎症反应 (由嗜中性粒细胞和激活的肺泡巨噬细胞主导)对糖皮质激素相对不敏感。 因此，所有慢阻肺临床指南都不推荐将ICS作为一线用药 哮喘的炎症反应本质上都是过敏反应（由嗜酸性粒细胞和CD4+淋巴细胞主导）,而过敏性炎症反应对糖皮质激素非常敏感。 因此，ICS被推荐为治疗持续性哮喘的一线用药 SAMA 必要时 或 SABA 必要时 LAMA 或 LABA LAMA 或 LABA + ICS A B D C LAMA和/或LABA + ICS ICS对慢阻肺炎症相对不起作用，因此，临床指南不推荐将ICS作为一线用药，而推荐LAMA为一线用药. ICS对慢阻肺炎症相对不起作用 * 慢阻肺中因氧化应激导致组蛋白去乙酰化酶减少可产生ICS抵抗 Barnes PJ. Br J Pharmacol. 2006;148(3):245-54.Ito K, et al. N Engl J Med. 2005; 352:1967-1976. 组蛋白乙酰化在气道炎症中起着重要作用：组蛋白乙酰化后激活编码炎症蛋白(TNF-α、IL-8和GM-CSF) 的基因转录 组蛋白去乙酰化酶(HDAC)可逆转NF-κB诱导的组蛋白乙酰化 (去乙酰化)，关闭炎症基因的激活 ICS