Management of the COPD Patient with Comorbidities: An Experts Recommendation Document.

Background: Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, which impact negatively on patients and are often underdiagnosed, thus lacking a proper management due to the absence of clear guidelines. Purpose: To elaborate expert recommendations aimed to help healthcare professionals to provide the right care for treating COPD patients with comorbidities. Methods: A modified RAND-UCLA appropriateness method consisting of nominal groups to draw up consensus recommendations (6 Spanish experts) and 2-Delphi rounds to validate them (23 Spanish experts) was performed. Results: A panel of Spanish internal medicine experts reached consensus on 73 recommendations and 81 conclusions on the clinical consequences of the presence of comorbidities. In general, the experts reached consensus on the issues raised with regard to cardiovascular comorbidity and metabolic disorders. Consensus was reached on the use of selective serotonin reuptake inhibitors in cases of depression and the usefulness of referring patients with anxiety to respiratory rehabilitation programmes. The results also showed consensus on the usefulness of investigating the quality of sleep, the treatment of pain with opioids and the evaluation of osteoporosis by lateral chest radiography. Conclusion: This study provides conclusions and recommendations that are intended to improve the management of the complexity of patients with COPD and important comorbidities, usually excluded from clinical trials.

Spanish clinical practice consensus in internal medicine on chronic obstructive pulmonary disease patients with comorbidities (miEPOC).

Background: Chronic obstructive pulmonary disease (COPD) is one of the diseases that leads to a higher number of hospitalizations in internal medicine departments. These patients are usually older and have greater multimorbidity than COPD patients hospitalized in other departments, which hinders the implementation of clinical guidelines necessarily focused on the management of a single disease.Aims: To ascertain the opinion of Spanish internists on the management of COPD in scenarios in which the available evidence is sparse and to produce a consensus document designed to assist in decision-making in COPD patients with comorbidities treated in internal medicine services.Methods: After identifying the clinical areas of greatest uncertainty by consensus, a survey was designed with 89 questions on the epidemiology and diagnosis of COPD, its management both in stable phase and during decompensation, and the treatment of the associated comorbidities in outpatients and inpatients. The consensus process was carried out using the Delphi method in an anonymized two-round process.Results: The survey was completed by 67 internists experienced in the clinical management of COPD. Of all the questions posed, a consensus was reached for 51 (57.3%) in the first round and for 67 (75.3%) in the second round. The result of the process is a series of 67 suggestions that may assist in the care of these patients.Conclusions: Our study allows us to ascertain the views of a large number of internists experienced in the management of COPD and to learn how the recommendations for guidelines are applied in clinical practice.

Combination Therapy With Glucagon-Like Peptide-1 Receptor Agonists and Sodium-Glucose Cotransporter 2 Inhibitors in Older Patients With Type 2 Diabetes: A Real-World Evidence Study.

OBJECTIVES: Scientific literature about the combination of glucagon-like peptide-1 receptor agonists (GLP-1ra) and sodium-glucose cotransporter 2 (SGLT2) inhibitors in older patients is scarce. We sought to assess the real-world efficacy and safety of SGLT2 inhibitors and GLP-1ra combination therapy in older patients (>65 years of age). METHODS: This was an observational, prospective, multicenter study based on clinical practice. Patients were stratified according to tertiles of baseline glycated hemoglobin (A1C) levels and to treatment schedule. RESULTS: We included 113 patients (65.5% men, mean age 70.4±8.8 years). The body mass index was 36.5 (±6.6) kg/m2. The baseline A1C level was 8.0% (±1.2%). At the 6-month follow up, we found a significant reduction in A1C levels (-1.1%; p<0.0001), body mass index (-2.1 kg/m2; p<0.00003) and systolic blood pressure (-13 mmHg; p<0.000005). Patients who had the highest baseline A1C levels (≥8.4%) showed greater improvement in A1C levels (p<0.0001), weight (p<0.0001) and quality-of-life scores (p<0.0001). The greatest reduction in A1C levels and weight was seen in patients who started both drugs simultaneously (p<0.0001). The second greatest reduction was seen when GLP-1ra was added to previous treatment with an SGLT2i (p<0.0001). Also of note was a decrease in systolic blood pressure in patients for whom an SGLT2i was added to previous GLP-1ra treatment (p<0.0001). Of the patients, 34.3% achieved the combined endpoint of A1C levels <7% and weight loss ≥5% without hypoglycemia. CONCLUSIONS: This study's findings provide evidence of clinically meaningful reductions in A1C level, body weight and systolic blood pressure in older patients with type 2 diabetes who are taking combined regimens. The dropout and hypoglycemia rates were minimal, and treatment was tolerated well.

Efectividad de una intervención simple sobre el tratamiento de las agudizaciones de la enfermedad pulmonar obstructiva crónica y de sus comorbilidades cardiovasculares: estudio COREPOC / Effectiveness of a simple intervention on management of acute exacerbations of chronic obstructive pulmonary disease and its cardiovascular comorbidities: COREPOC study

Fundamento y objetivo: Analizar la efectividad de una intervención educativa simple para mejorar el tratamiento de las comorbilidades cardiovasculares en los pacientes hospitalizados por una exacerbación de enfermedad pulmonar obstructiva crónica (EPOC). Material y métodos: Estudio multicéntrico con participación de 26 hospitales. Un grupo de expertos elaboró unas recomendaciones para el abordaje diagnóstico y terapéutico de la EPOC y las comorbilidades cardiovasculares (cardiopatía isquémica, fibrilación auricular, insuficiencia cardiaca y diabetes) que se graduaron como imprescindibles, aconsejables y sobresalientes. Se recogió el cumplimiento de las recomendaciones en los informes de alta de los pacientes ingresados en los servicios de Medicina Interna por reagudización de la EPOC. Se realizó una sesión clínica explicando los protocolos de atención a las comorbilidades en la EPOC y al cabo de 6 meses se volvió a observar el cumplimiento de dichas recomendaciones. Resultados: Se recogieron 390 casos antes y después de la intervención. Hubo mejoría significativa en el 53% de los ítems y esta mejoría fue mayor en los referidos al tratamiento general (66,7%) y al tratamiento de la EPOC (76,9%) y menor en los referidos a la cardiopatía isquémica (0,0%) y a la insuficiencia cardiaca (11,1%). Tras la intervención mejoró el cumplimiento de las recomendaciones en general (p=0,020) y de las imprescindibles (p=0,017), con una tendencia a la mejoría en las aconsejables (p=0,058) y las sobresalientes (p=0,063). Conclusiones: Una intervención simple puede mejorar la atención a los pacientes con exacerbación de EPOC, especialmente en el tratamiento de la enfermedad pulmonar, con pequeños cambios en el de las comorbilidades (AU)

Background and objective: To determine the effectiveness of a simple educational intervention to improve the management of cardiovascular comorbidities in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Material and methods: Multicenter study participated in by 26 hospital centers. A panel of experts elaborated a set of recommendations about diagnostic and therapeutic management of acute exacerbation of COPD and cardiovascular comorbidities (coronary artery disease, atrial fibrillation, heart failure and diabetes). The recommendations were graduated as indispensable, advisable and outstanding. Compliance with recommendations were assessed in the discharge letter for COPD patients hospitalized with acute exacerbation in Internal Medicine departments. The protocols to treat the comorbidities in COPD were explained in a clinical session. After 6 months’ compliance with recommendations they were reassessed. Results: A total of 390 cases before and after the intervention were assessed. There was significant progress in 53% of cases. The improvement was greater in cases referred to general management and COPD management (66.7 and 76.9%, respectively), and lower in cases referred to ischemic heart disease (11.1%) and none in those referred to coronary artery disease. After the intervention, the adherence to overall and indispensable recommendations was higher (P=.020 and P=.017, respectively) and a trend to improve was observed in advisable (P=.058) and outstanding recommendations (P=.063). Conclusions: A simple intervention can improve the management of lung disease in COPD patients with an acute exacerbation, but has less effect on the management of comorbidities (AU)

Effectiveness of a simple intervention on management of acute exacerbations of chronic obstructive pulmonary disease and its cardiovascular comorbidities: COREPOC study. / Efectividad de una intervención simple sobre el tratamiento de las agudizaciones de la enfermedad pulmonar obstructiva crónica y de sus comorbilidades cardiovasculares: estudio COREPOC.

BACKGROUND AND OBJECTIVE: To determine the effectiveness of a simple educational intervention to improve the management of cardiovascular comorbidities in patients hospitalized with an acute exacerbation of chronic obstructive pulmonary disease (COPD). MATERIAL AND METHODS: Multicenter study participated in by 26 hospital centers. A panel of experts elaborated a set of recommendations about diagnostic and therapeutic management of acute exacerbation of COPD and cardiovascular comorbidities (coronary artery disease, atrial fibrillation, heart failure and diabetes). The recommendations were graduated as indispensable, advisable and outstanding. Compliance with recommendations were assessed in the discharge letter for COPD patients hospitalized with acute exacerbation in Internal Medicine departments. The protocols to treat the comorbidities in COPD were explained in a clinical session. After 6 months' compliance with recommendations they were reassessed. RESULTS: A total of 390 cases before and after the intervention were assessed. There was significant progress in 53% of cases. The improvement was greater in cases referred to general management and COPD management (66.7 and 76.9%, respectively), and lower in cases referred to ischemic heart disease (11.1%) and none in those referred to coronary artery disease. After the intervention, the adherence to overall and indispensable recommendations was higher (P=.020 and P=.017, respectively) and a trend to improve was observed in advisable (P=.058) and outstanding recommendations (P=.063). CONCLUSIONS: A simple intervention can improve the management of lung disease in COPD patients with an acute exacerbation, but has less effect on the management of comorbidities.

Hyperglycemia management in patients admitted to internal medicine in Spain: A point-prevalence survey examining adequacy of glycemic control and guideline adherence.

AIMS: Despite the increasing prevalence of hospitalized diabetic patients, there are few studies that evaluate the glycemic control and the rate of adherence to clinical practice guidelines for glucose monitoring and management in the hospital setting. METHODS: Crossover study using one-day surveys of all inpatients admitted to internal medicine wards from voluntary participating hospitals across Spain. Retrospective review of medical records was used to identify patients with hyperglycemia, causes for hospitalization, patients' demographic characteristics, appropriateness of glycemic monitoring and treatment during hospitalization. RESULTS: Among 5439 hospitalized patients studied there were 1000 (18.4%) with hyperglycemia in 111 participating hospitals. Patients mean age was 76.0±8.5 years (51.6% male). On admission, 91% had known diabetes (disease duration of 10.9±8.5 years), 5% had unknown diabetes and 4% had stress hyperglycemia. The comorbidity index (Charslon score) was 4 (interquartile range: 2 to 6) and 31% showed a high level of disability (Rankin scale). Main infringement in the process of care included lack of a recent HbA1c value (43.7%), use of sliding scale insulin therapy (20.7%), use of oral antidiabetic agents (8.9%), and less than three bedside point-of-care (POC) blood glucose test per day (17%). Glycemic target pre-meal and bedtime were achieved in 47% to 79.5% of POC. The rates of hypoglycemia (<70 mg/dL and <50mg/dL) were 10.3% and 2.4%, respectively. CONCLUSIONS: Our results suggest that there is an important gap between the clinical guidelines and both the management and the grade of glycemic control of diabetic inpatients.