Video Understanding the Year 2020 ATS/ERS/ESCMID/IDSA Guidelines: Applying Evidence-Based Guidelines to the Front Lines of MAC Lung Management Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides Understanding the Year 2020 ATS/ERS/ESCMID/IDSA Guidelines: Applying Evidence-Based Guidelines to the Front Lines of MAC Lung Management Overview good day, everyone. And thank you for joining me for a time to try to understand the new 2020 NTM guidelines using a case based approach. My name is Dr Billy Philly. I'm a pulmonologist practicing here in Tyler, Texas. A place that's been well known for NTM lung disease for a long time. So I hope that together we can kind of navigate some of these new changes and maybe experience a little about about what I do in my own clinical practice. So again, thank you for joining me. Just a quick disclosure slide. Thio let you know what I've been participating in. And now to talk about these new guidelines, you know, the old guidelines were released in 22,000 and seven. So 30 years went by and we've been anticipating these new 2020 guidelines for some time. Made up of many distinguished, um uh huh. Different types of people across many types of countries. And a new agreement was made about the new treatment and how we deal with some of these difficult cases. So I appreciate all of the collaborators and people and friends that have made these guidelines happen again. Just taking a quick look at them further for your reference and for your information so a bit about what has not changed in the guidelines. First of all, the criteria for diagnosis, many of you will remember that we need three things to make the diagnosis of NTM lung disease, you need positive micro biologic cultures. You need at least two positive sputum or something else that's positive and culture, perhaps from a bronc, reveal or wash lavage or a biopsy. You also need consistent radiographs, either by cat scan image ing, usually with bronchi ECT assist with novels or kava terry disease. And then you also need symptoms which are consistent within TM. So this has not changed in the 2020 guidelines. In addition to that, we don't exactly understand from the data exactly how long to treat people. So the duration of therapy has also not changed. You need 12 months of negative cultures while on therapy, uh, to to meet the diagnosis for adequate treatment. Also, I just want to point out this is that not all patients who diagnostic criteria and I know many of you have seen this in your own practice need to be treated with. That being said, the guidelines suggest initiation if they're over watchful waiting in particular patients, especially factors, and we'll go over over that in just a minute. Again. Just talking about the diagnosis of Mac lung disease. Forget that consistent clinical simply include things like fatigue off weight loss, Hamat, Asus, sometimes night sweats. Those consistent radiographs are very important. Along with appropriate micro biologic data. Let's talk a little bit about treating or not to treat. Um, you know many people there's missed out there. I still hear this every day. The treatment is worse than having the disease itself, or you'll die with the disease instead of the disease. Or don't worry, those antibiotics were so tough to take this impossible to treat, so lines do their best. Press this in patients that meet criteria. The guidelines suggest going ahead and treating over the watch hitting, and they do give some guidance in certain areas. If you have a patient with kava terry disease, they treated. In addition to that, if you have a patient that is developing smear positivity or comes to you with significant radio with smear positive sputum, you can assume that their burden of disease is pretty high, and the guidelines suggest going ahead and treating these patients. I think we all have to recognize there's still an art to practicing medicine and NTM lung disease is no different. So you really have to take all accounts into considerations when considering starting people on these antibiotic regiments. I put this flight up here because it's still really important to look at your ass and to understand the difference and patterns because it not only predicts treatment regimens that will predict how often these people need to take these regiments. So I just have up here, Cem bronchi. It tastes as bronchi actresses patients. You can see these dilated floppy bronchial tubes and all of these pictures. Some are focal. Some are more amid Long Central, and this is opposed to this being a different type of patient. Typically, cava terry disease, cava terry disease can occur throughout the lungs, but most often is upper lobe and is often associated with emphysema. Two different types of patients to different types of treatment options are recommended in these folks, so it's important to be ableto radiographs and get a sense of what's going on. So let's talk about some cases. An 82 year old comes to your office with a cough. Diagnosed a couple years ago, she's had an abnormal chest image and was positive by a FB culture for Matt. She was placed on three times weekly therapy of chloroform eyes and the family, telling her fan that developed some symptoms. So they thought this might be too to the chloroform. Eso she was changed was epitomized in the family, telling her a phantom. And she comes back to your office with continued cough in a weight loss of £4 multiple complaints about the antibiotics. So just going a bit further into her case, you can see that she has some mid long bronchi emphasis on the rights. Um, sinusitis. Some other co morbidity is she's had a his direct me in the past. Her father had lung issues but was a heavy smoker. She herself has never smoked and does not have any clear exposures such a sitting in a hot tub, steam shower or a sauna. I think this is a important piece of the guidelines that we need Thio highlight, and you should recognize first of all in nodule or bronchi. Bronchi actresses, patients that air macro light susceptible three times weekly therapy is better tolerated and recommended over a daily regimen. This is for the guidelines and through several large studies that have been done in in multiple different institutions. This is opposed to the cava Terry patient, and you can see here on the right hand side of your screen that this patient has, ah, large right side, then necessitates daily therapy with the addition of an injectable. I mean, unlike aside or some kind of intensification of therapy. Now, with this being said, in addition to Cava Terry disease, patients with severe disease or patients that have been refract past also may benefit from daily therapy. And I think this is an important distinction in your clinical practice to make. I also wanted to talk about sputum culture results, and I wanted to show you a couple of real life patient cases that I see practice, and this is a just a picture of how we report our sputum cultures at my institution. We showed the sputum stain, which this patient has smear positivity of one plus. We showed the culture and we showed the broth just a bit about how we quantify sputum, that our institution and I recognize you out there don't have the ability to do this. You have to take it in context. You know that you have to have an adequate specimen to understand Quantitative sputum results that these can vary. They can be misleading if taken out of context. They're difficult to use for the primary in points of studies, and many laboratories can't do them. But over time, used in the right way, they can be helpful to God. Your therapy. People ask me all the time about susceptibilities world I interpret thes and how do I use some of you obviously understand this concept and many of you out there May I want to tell you you're not alone because they could be misleading. Often times there are many different types of reports that are sent with conflicting information about how to use these. And so I wanted to show you a few of these reports, but also highlight the difference in the 2020 guideline because this is another key point that you need to take home. So this is just example of susceptibility reports from A from a culture showing the M I. C s for a variety of drugs. But as you can see at the bottom, they actually annotate the clareth reminds and m i C is being susceptible. This is gin is just an exam. Another example from a different institution shows a lot more information. Um, that for a variety of also many drugs but also still from a Mac sample that shows the M I C is to be resistant, susceptible or tentative interpretations which can be difficult to understand. Um, if you're not experienced with using these yeah, another susceptibility report. Just showing the check mark in the box for susceptibility again. Also showing this am hasten 16, which turns out in 2020. You would also put a check mark in this box because it is susceptible. So all this tell you the new changes in the guidelines. Mackerel. It's an amicus sins. I am a cason Are the two drugs that you care about for Mac lung disease? What does this mean? It means that treatment success correlates with the in vitro susceptibility of clareth Armisen and for Amma Cason. So this is an important thing to note. Yes, that's what I'm telling you. If you see an intermediate or a resistant by a family, tolerate fam pin. That does not mean you should not use those drugs. Conversely, if you see that you have a Mac patient that has a resistant organism, you need to understand that those treatment options are different and often limited and may need to have an outside referral if you do not feel comfortable of dealing with these patients. It's also important to note in terms of monitoring patients that end up on these drugs that you need to monitor these patients very closely, especially when being on am a case in. And I wanted just to highlight that. ODA toxicity remains very common in these patients, and you need to check for this while they're on these drugs. So just going on with our clinical case, this patient continued on triple drug therapy. I also want to point out in the new guidelines that azithromycin is preferred over clear through Meyssan due to tolerable ity, daily dose ing and the fact that it is not inferior to clear through my zing. So this page, what's continued on these three drugs. The patients treated for a gram negative that was growing in their sputum for clips yellow and placed on airway clearance with improvement and symptoms. And this patient went on to complete 12 months of successful treatment with negative culture. So this was a success story and in a good case toe, understand these key points macro lies an indication are very important in the new guidelines. You should check these upfront, make sure that the patient is susceptible these two and then place them on guideline based therapy. And in addition, you may need to repeat susceptibility if you end up with a patient that does not convert their sputum too negative again pointing out that azithromycin is preferred and that three Times weekly therapy is recommended in modular bronchial Tadic disease, let's do another case. And a 56 year old again with a history of nodule or bronchial disease, referred to your clinic for felt treatment of guideline based therapy. This patient has taken daily therapy for eight months, originally referred to infectious disease with Midland Bronchi X in a persistent cough. When the patient comes to you with four positive sputum for Mac, very recently within the past 2 to 3 months. CO morbidity is include mild depression and hypertension, and the patients on some thyroid replacement and some antidepressant medication. In In the first clinic visit that you have with this with this patient, you check in you know glob, which were normal. Alfa one level sweat chloride connected tissue serology Ease again. You know, just looking for reasons this patient might have bronchi actresses. All of these things were done revealing and you repeated a culture for Mac. I mean, rather for AFB in your clinic and the patient grew Mac, you repeated susceptibilities and the patient remained clear for mice and susceptible with an M I C of eight. So again, just pointing out this modular, bronchial Tadic film that you can see with some mucus plugging specifically on left. So what would you do next? Would you change the patient's medications to three times weekly to improve side effects? Remember, this patient has been on therapy daily for at least eight months. Would you change for fam pin to Cliff Azemi? Would you repeat the susceptibilities and add inhaled liposomes Emmett cases for oral antibiotics? Or would you just stop all of her therapy and repeat imaging in six months. This is always a point in time where I wish we were together and could see faces, but I think that there's some pros and cons to each of the different letters. But in general, what I do is repeat susceptibilities, which was done to make sure that clareth remission remain susceptible and am a case in does. And then if the patient has factory disease, meaning they've been on guideline based therapy for at least six months and remain culture positive. Many people and the guidelines highly suggest adding inhaled liposomes education, and we're going to go over the Why thio to this to this question. So let's again talk about the guidelines and mention that I am a case in liposomes inhalation suspension or Alice or Ivy Amma. Cason is recommended for these refractory patients. Again. You place the patient on therapy and you check their sputum. Is everyone two months. The guidelines suggest that you do this again. How do you know if they've cleared this from their sputum? Unless you're checking and they're still positive with symptoms, then escalation of the therapy is now recommended based on strong evidence. How did this evidence coming into place? Well, there's a study called The Convert Study. Specifically, looking at this life is so more inhale form and that there were two arms. One was the inhale plus guideline based therapy, and this was compared to guideline based therapy alone. The drug was Alice or this life possible inhaled form used once a day. And the primary in point of this study was culture conversion by six months. So you can imagine you take a bunch of patients that have not converted their sputum, and you say you're going to have to have sputum conversion by six months. With three months consecutive. That essentially means the patient must have converted their sputum by month four to have month 45 and six b negative to reach the primary endpoint. What did the studies show? Well, it showed that 29% of patients in the arms inhale dammit case and plus guideline based therapy converted their sputum by that month. Four. To reach statistical significance versus guideline based therapy alone, respiratory events were noted more frequently, as you can imagine, inhaled great versus just the aural group. But again it was noted that this was a statistically significant study that's been reproducible. And we believe that this is a very important part of the new treatment options for factory Mac along patients. Yeah, looking at this case again, Um, this patient was placed, um, on excuse me on therapy. Um, and you don therapy and unfortunately, continue to have positive sputum. Her B m I and symptoms were slightly improved, but she was still symptomatic with cough and not feeling well. And so the decision was made to continue her on daily Orel Mac medications And to add Alice once daily as per the guidelines again, a reminder you don't know if people convert unless you check their sputum. So the patient returns four weeks later with cough, some changes in her voice. And she said, You know, I want to be sure that I don't permanently damaged my voice books or have a problem. What do I dio? This is an important part of drug tolerable ity that I think warrants a minute of our time. The use of inhaled like the soma Amit Cason is associated with an increasing coffin. Dis phony. Um, and up to 50% of the time. You may hear about this from your patients, so the first thing you need to do is warn patients. If you use this drug that they should expect, Thio have the side effects we understand from the studies. And I can tell you from personal um, use of this impatience that the side effects are typically not long term. And if the patients stay on the drug and can tolerate the drugs, these usually get better with time. There are some things you can do. Thio minimize this or to improve it sometimes hot tea mouthwash. Tages Los Anges mouthwashes. Um, using a bronchodilator 30 before use have been some helpful techniques. So this patient was able to continue on drugs and developed her first negative AFB culture four months after taking Alice and remained on guideline based therapy. And it's still on therapy today, hoping to complete successful 12 months of cultures in the next five months. So some tips on how to optimize regiment adherents when people develop side effects. If people develop nausea on antibiotics, you can tell them, try taking it at a different time of the day. Take it at night, prior to going to bed or take it early in the morning. Um, take it with different types of food, provided that it's an antibiotic, that you're able to do so. If one particular antibiotic is causing the side effect, you can consider, um, changing the dose schedule. Culprit drug. In other words, you may be able to get away with one drug that's three times weekly, while others or daily. If you needed to again, you should prepare people to have some side effects within hill drugs, hoarseness, cough, chest tightness or commonly reported. The majority of patients can handle this, but occasionally what we'll do is have them reduce the frequency of how often they're taking it, um, or start slowly so that they can it become accustomed to the drug. But the big factor really is patient communication and how you communicate with the patient. When you have a relationship with someone and you are committed to getting them through successful treatment the majority of the time, you'll be able to do that. And so if you have decreased someone's, um, regimen where they're taking it every other day, many patients over time can work back to that daily dose and schedule. And I believe I mentioned some of these other therapy options to try just to see if you can minimize some of the other side effect. So key points from this case again highlighting the differences in the 2020 guidelines in patients with Mac who have felt therapy after at least six months of guidelines. Therapy guidelines recommend adding Alice to the treatment regimen instead of continuing on the aural regiment alone. Also important to point out that inhale therapies such as generic inhaled Emma, Cason or Alice are not currently recommended for initial treatment for patients with Mac loan disease, and that you should anticipate some side effects with the aural regiment and within held regimens and be able to talk to your patients in order to help them through. Let's move on to third case, Um, sometimes, you know, you sit in your clinic, and the first thing you do is open a radiograph to see what's going to come next. So a little bit of a different um approach here today, but you open this this X ray of a patient, and immediately you can see you have some major issues in the right lung. And so before you worry too much, you dive into the case. This is a 66 year old patient with a history of COPD that is referred to you for lung disease. The patients diet knows for some time at least six years ago, and at the time the patient did not have treatments because the symptoms were mild and they thought the shortness of breath was mostly from COPD. You can see by lung function that this patient has FCB one of about a leader, and and that's on side. She has severe obstruction. She has a history of having bronchi act assist in her family, and she has significant smoking history. But the good news is that she quit last week, and she's committed Thio trying to stop the cigarettes, most of which, she admits, is due to severe shortness of breath. And she does not use alcohol. So you have sputum that is available for your view. Unfortunately, she's grossly positive by by culture. Her plate grew four plus of Mac. She was susceptible to clareth remission. As you can see, she has a susceptibility of and M. I C. Of two she's susceptible again. I put the others on their to trick you to make sure you're listening. But if your eyes gazed down to the M A case and M. I C of 16, which is also susceptible, you know that you're in good shape and that you can move towards a treatment regimen for her. If indicated, past medical history includes baseline hearing loss, hypertension and COPD. Again automatically. You think baseline hearing loss. I've got to minimize drugs if I can, or at least follow her related Thio her hearing in order to save as much as I can. Ah, this is a culture result again, just showing four plus and sneer four plus and culture. This is just a very high burden of Mac lung disease in this individual, and this is a copy of her CAT scan. Uh, this is an upsetting situation because this is severe cava terry disease, and you can see some emphasis. Metis changes throughout the lungs as well. But as you scroll down, what you can tell is that not only does she have a significant cava Terry burden on the right, she also has disease and small capitation on the left, which are very impressive. It is worth our time. Toe highlight cava Terry Mack Lung disease is a serious, serious event that should be treated. Treatment outcomes, we know, are worse in kava terry disease, and I see it in my practice, often at least weekly that a patient comes to me on inadequate therapy because providers have not been aggressive enough to treat their cava terry disease the use of intravenous. You know, black aside can increase culture conversion. And for this reason, aggressive therapy is warranted in the guidelines. I've Iemma Cason strip demise and is another option is given a doses for 18 to 16 weeks. In addition, toe oral medications. And here's what I can tell you. This is from personal experience. These air guidelines 8 to 16 weeks is a reasonable amount of time, but it may be necessary to go longer in patients with severe capitation, especially if they're not a full candidate and especially if they ended up being macro live resistant again. Noting that Amina glad decides, are associated with renal dysfunction and with hearing loss. And so you have to take these into account and then some experts we do consider the use of in Held, um, a case in. In these cases, I think we're still trying to answer the questions about the wind and the how and the who and the and the which patient is the best. But if you severe cava terry disease, you should start with an intravenous drug. That's the recommendation for most experts. So again, Pete everything. Making sure that the susceptibilities are correct and this patient remains cloth reminds and endemic case and susceptible. But she's describing to you that she just has terrible shortness of breath. She is requiring oxygen. She does have baseline hearing loss and describes ringing in her ears. And so she was on daily medications and you to change her medications. Or I opted to change her medications to IBM Dickason, which to start, I started three times weekly trying to, um see if she could tolerate this and what the side effects would be and then placed her on daily oral therapy with the drugs that you see listed here again. An aggressive approach but a patient and a cat scan that weren't such so she was treated with all of these things, but she called back pretty pretty, pretty pretty near right away and said I've got a terrible rash and I have a temperature of 102 on Refer Mutant. So she was switched to her family in just a tidbit. Oftentimes, high fevers associated with these drugs is often by Aretha Meyssan. Um, never hurts to stop everything and make sure that the patient does okay for a few days. But often times it is the rhythm eyes, and it causes that. And so paperwork was completed for her to start on. Co Fasani. I, uh, the data for Cliff Azmin is limited, but we do know that in some studies this could be used as a replacement, especially for reform is in and that it does have, um, some activity against Mac in the laboratory. And so this was placed on this drug recognizing. It's not always easy to get, and you do have to take some extra measures. Um, and unfortunately, as I mentioned due to this cava Terry nature of her least, she's not a surgical candidate. I think it's important to point out in kava terry disease with isolated capitation as an example, someone with adequate lung function, but on Leah right upper cavity after you aggressively treat them with daily therapy and an ivy amino Black aside, if you're not making headway, surgery can be considered to remove that night US of infection, and patients can do well in patients with bilateral severe disease. This is not an option. And unfortunately, this patient has a low B m in a very poor functional capacity, and surgery was not considered so again bringing home, he points one more time for the road. The focus on macro light in case of susceptibility and the new guidelines is very mhm. Also, please note regimen, dozing nodule or bronchi act tactics may get away with three times weekly therapy. But for kava terry disease, an injectable Amina black aside has indicated, plus daily therapy again noted for refractory disease, meaning just stays positive. And the addition of a drug like Alice may be warranted or is recommended, and then resistant infections often require expert opinion. If you don't know how to treat thes, I would recommend calling. You're phoning a friend for help, and then the consideration of surgery in isolated disease remains very important. So, in summary, initiating treat from for macron disease does require thoughtful consideration, but don't wait too long. If you see a patient, especially that's near positive. Has Cavite ations is getting worse. You need to treat them rather than watch a in a note that they get worse over time, you need to understand susceptibility patterns and what drugs math. Remember Macro Lights and Emma Case in understanding those radiographic patterns as it does influence dozing schedules and regimens and then just appreciate that there is a new therapy in the form of Alice for fracturing Mac lung disease that is recommended by the guidelines. So there's educational resource is that are available, including this Revenue are which is available as an enduring resource resource on the website that you see listed here. I want Thio again thank colleagues from around the country for participating in things like this, because I do think it helps answer questions in this, um, disease state, which fortunately is receiving better recognition. It and doctors, patients and treating physicians understand MAWR today than we did 13 years ago, with the old 2000 and seven guidelines again just noting that there are many experts in this field and that there are multiple resource is for you to use to look at the frequently asked questions on how to treat this These air interactive, these air downloadable um their resource is for CMI. They easy obtainable for use on your phone table, top or just top. And so with that, I'd like to thank you for your attention and wish you a good day. Take care. Published Created by
