Dove Medical Press



Supplementary table 1. Conclusions on extrapulmonary manifestations of COPD and comorbiditiesConclusions (C) and Recommendations (R)Final resultsLevel of evidence (LE)/Grade of recommendation (GR)SourceComorbiditiesThe sustained presence of low grade systemic inflammation in COPD contributes to the emergence and development of comorbidities.Unanimity1st round5DReferencesPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYXJuZXM8L0F1dGhvcj48WWVhcj4yMDAxPC9ZZWFyPjxS

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dGU+PC9FbmROb3RlPgB=

ADDIN EN.CITE.DATA 1-3Supplementary table 2. Conclusions and recommendations on the clinical consequences and treatment of cardiovascular risk factors in COPD patientsConclusions (C) and Recommendations (R)Final resultsLevel of evidence (LE)/Grade of recommendation (GR)SourceA) OBESITYConsequences of obesity in COPDObesity in COPD patients causes respiratory function changes that lead to worse quality of life, reduced exercise tolerance, and greater use of health care resources.Unanimity1st round2References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYXJjaWEtUmlvPC9BdXRob3I+PFllYXI+MjAxNDwvWWVh

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ADDIN EN.CITE.DATA 4-6Patients with COPD and obesity should receive recommendations for weight control.Unanimity1st round5 DCompiled by authorsExpert opinionPatients with low body weight should receive recommendations on nutrition and physical activity aimed at gaining weight and muscle mass, given the association between low BMI and mortality.Consensus(97.5%)1st round5 DCompiled by authorsReference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYW5vPC9BdXRob3I+PFllYXI+MjAwMjwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 7Treatment of patients with COPD and obesitySystemic corticosteroids can contribute to weight gain if used for extended periods of time.Unanimity1st round2Reference:PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DdXJ0aXM8L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 8Roflumilast can cause weight loss.Consensus(95.7%)1st round1Reference: ADDIN EN.CITE <EndNote><Cite><Author>Yuan</Author><Year>2016</Year><RecNum>3752</RecNum><IDText>Potential treatment benefits and safety of roflumilast in COPD: a systematic review and meta-analysis</IDText><DisplayText><style face="superscript">9</style></DisplayText><record><rec-number>3752</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552034980">3752</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Yuan, L.</author><author>Dai, X.</author><author>Yang, M.</author><author>Cai, Q.</author><author>Shao, N.</author></authors></contributors><auth-address>Department of Respiration, Tianjin Hospital of ITCWM (Tianjin Nankai Hospital)Department of Pharmacy, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy, Tianjin, People’s Republic of China</auth-address><titles><title>Potential treatment benefits and safety of roflumilast in COPD: a systematic review and meta-analysis</title><secondary-title>Int J Chron Obstruct Pulmon Dis</secondary-title></titles><periodical><full-title>International Journal of Chronic Obstructive Pulmonary Disease</full-title><abbr-1>Int. J. Chron. Obstruct. Pulmon. Dis.</abbr-1><abbr-2>Int J Chron Obstruct Pulmon Dis</abbr-2></periodical><pages>1477-83</pages><volume>11</volume><dates><year>2016</year></dates><isbn>1176-9106 (Print)1178-2005 (Electronic)</isbn><accession-num>27418821</accession-num><urls><related-urls><url> LE: 1All lifestyle and dietary modifications and pharmacological treatments that contribute to optimum control of excess weight are recommended.Unanimity1st round5 DCompiled by authorsExpert opinionPulmonary rehabilitation programs are recommended in patients with COPD and obesity.Unanimity1st round5 DAdapted from ADDIN EN.CITE <EndNote><Cite><Author>Díez-Manglano</Author><Year>2014</Year><RecNum>39592</RecNum><IDText>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</IDText><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>39592</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552094241">39592</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Díez-Manglano, J.</author><author>López-García, F.</author></authors></contributors><titles><title>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</title><secondary-title>Sociedad Espa?ola de Medicina Interna (SEMI) y Elsevier SL</secondary-title></titles><pages>1-259</pages><dates><year>2014</year></dates><isbn>978-84-7592-7626</isbn><urls><related-urls><url><style face="underline" font="default" size="100%"> face="normal" font="default" size="100%">.</style></url></related-urls></urls></record></Cite></EndNote>10 References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TYXZhPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 11,12B) ARTERIAL HYPERTENSION (AHT)Consequences of AHT in COPDA comprehensive evaluation must be performed to detect risk factors associated with COPD and AHT in all patients with both diseases, since these conditions will foster the development of cardiovascular diseases, such as ischemic heart disease and congestive heart failure, that worsen the prognosis of COPD patients.Consensus(95.7%)1st round5 DAdapted from ADDIN EN.CITE <EndNote><Cite><Author>Díez-Manglano</Author><Year>2014</Year><RecNum>39592</RecNum><IDText>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</IDText><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>39592</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552094241">39592</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Díez-Manglano, J.</author><author>López-García, F.</author></authors></contributors><titles><title>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</title><secondary-title>Sociedad Espa?ola de Medicina Interna (SEMI) y Elsevier SL</secondary-title></titles><pages>1-259</pages><dates><year>2014</year></dates><isbn>978-84-7592-7626</isbn><urls><related-urls><url><style face="underline" font="default" size="100%"> face="normal" font="default" size="100%">.</style></url></related-urls></urls></record></Cite></EndNote>10 Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYWthYmF5YXNoaTwvQXV0aG9yPjxZZWFyPjIwMTA8L1ll

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ADDIN EN.CITE.DATA 13Treatment of patients with COPD and AHTBronchodilators (long acting muscarinic antagonists and long acting beta agonists) are safe and well tolerated in hypertensive patients with COPD.Unanimity1st round5Reference: ADDIN EN.CITE <EndNote><Cite><Author>Grupo de Trabajo de GesEPOC</Author><Year>2017</Year><RecNum>3587</RecNum><IDText>Guía de Práctica Clínica para el Diagnóstico y Tratamiento de Pacientes con Enfermedad Pulmonar Obstructiva Crónica (EPOC) – Guía Espa?ola de la EPOC (GesEPOC). Versión 2017</IDText><DisplayText><style face="superscript">14</style></DisplayText><record><rec-number>3587</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552034924">3587</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Grupo de Trabajo de GesEPOC,</author></authors></contributors><titles><title>Guía de Práctica Clínica para el Diagnóstico y Tratamiento de Pacientes con Enfermedad Pulmonar Obstructiva Crónica (EPOC) – Guía Espa?ola de la EPOC (GesEPOC). Versión 2017</title><secondary-title>Arch Bronconeumol</secondary-title></titles><periodical><full-title>Archivos de Bronconeumologia</full-title><abbr-1>Arch. Bronconeumol.</abbr-1><abbr-2>Arch Bronconeumol</abbr-2></periodical><pages>2-64</pages><volume>53</volume><number>Suppl 1</number><dates><year>2017</year></dates><urls></urls></record></Cite></EndNote>14Treatment of AHT is the same in patients with and without COPD, and COPD treatment is the same in patients with and without AHT.Unanimity1st round5Expert opinionThe use of beta-blockers, especially cardioselective agents, is recommended in hypertensive patients with COPD and ischemic heart disease or heart failure.Unanimity1st round2 BAdapted from PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EaSBEYW5pZWxlPC9BdXRob3I+PFllYXI+MjAxNTwvWWVh

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ADDIN EN.CITE.DATA 16,17Cardioselective beta-blockers should not be suspended during acute COPD exacerbations.Consensus(91.3%)1st round2 BCompiled by authorsReference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EcmFuc2ZpZWxkPC9BdXRob3I+PFllYXI+MjAwODwvWWVh

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ADDIN EN.CITE.DATA 18In patients with COPD and AHT, antihypertensive treatment with angiotensin converting enzyme inhibitors and angiotensin receptor II blockerss is recommended.Consensus(91.3%)1st round5 DAdapted from ADDIN EN.CITE <EndNote><Cite><Author>Díez-Manglano</Author><Year>2014</Year><RecNum>39592</RecNum><IDText>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</IDText><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>39592</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552094241">39592</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Díez-Manglano, J.</author><author>López-García, F.</author></authors></contributors><titles><title>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</title><secondary-title>Sociedad Espa?ola de Medicina Interna (SEMI) y Elsevier SL</secondary-title></titles><pages>1-259</pages><dates><year>2014</year></dates><isbn>978-84-7592-7626</isbn><urls><related-urls><url><style face="underline" font="default" size="100%"> face="normal" font="default" size="100%">.</style></url></related-urls></urls></record></Cite></EndNote>10 Expert opinionCOPD should be treated according to standard clinical practice guideline recommendations, since there is no direct evidence that COPD should be treated differently in the presence of hypertension.Unanimity1st round5 DCompiled by authorsExpert opinionC) DIABETES MELLITUS (DM)Consequences of DM in COPDDiabetes mellitus is associated with worse quality of life, shorter time until first hospitalization, longer hospital stays, and increased mortality.Unanimity1st round2References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYWNrZXI8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 19-29In patients with COPD and obesity or other cardiovascular risk factors, the presence of diabetes mellitus should be ruled out, due to its impact on quality of life, COPD progress, and reduced survival.Unanimity1st round2 CCompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYWNrZXI8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 19-29As in any patient with DM, in patients with COPD and DM, glycated hemoglobin (HbA1c) must be determined periodically in order to maintain an optimal degree of glycemic control, due to the increased relative risk of death or prolonged length of hospital stay associated with high blood glucose.Unanimity1st round2 CCompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGFrcmFiYXJ0aTwvQXV0aG9yPjxZZWFyPjIwMDk8L1ll

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PC9FbmROb3RlPgB=

ADDIN EN.CITE.DATA 13,28-30Treatment of patients with COPD and DMLow-dose inhaled corticosteroids, when indicated, do not increase the risk of developing DM in patients with COPD.Consensus(87.0%)1st round2References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5PJmFwb3M7QnlybmU8L0F1dGhvcj48WWVhcj4yMDEyPC9Z

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ADDIN EN.CITE.DATA 31Blood glucose should be monitored in patients with COPD who receive treatment with systemic corticosteroids, due to the increased risk of development of hyperglycemia.Consensus(87.0%)1st round2 BCompiled by authorsReference: ADDIN EN.CITE <EndNote><Cite><Author>Wood-Baker</Author><Year>2005</Year><RecNum>38504</RecNum><IDText>Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease</IDText><DisplayText><style face="superscript">32</style></DisplayText><record><rec-number>38504</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552090889">38504</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wood-Baker, R. R.</author><author>Gibson, P. G.</author><author>Hannay, M.</author><author>Walters, E. H.</author><author>Walters, J. A.</author></authors></contributors><auth-address>Medicine, University of Tasmania, GPO Box 252-34, 43Collins Street, Hobart, Tasmania, Australia, 7001. Richard.WoodBaker@utas.edu.au</auth-address><titles><title>Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease</title><secondary-title>Cochrane Database Syst Rev</secondary-title><alt-title>The Cochrane database of systematic reviews</alt-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title><abbr-1>Cochrane Database Syst. Rev.</abbr-1><abbr-2>Cochrane Database Syst Rev</abbr-2></periodical><pages>Cd001288</pages><number>1</number><edition>2005/01/28</edition><keywords><keyword>Acute Disease</keyword><keyword>Administration, Oral</keyword><keyword>Glucocorticoids/*administration &amp; dosage</keyword><keyword>Humans</keyword><keyword>Lung Diseases, Obstructive/*drug therapy</keyword><keyword>Randomized Controlled Trials as Topic</keyword></keywords><dates><year>2005</year><pub-dates><date>Jan 25</date></pub-dates></dates><isbn>1361-6137</isbn><accession-num>15674875</accession-num><urls><related-urls><url> any patient with DM, glomerular filtration rate should be evaluated periodically to adjust the dose of antidiabetic drugs in patients with COPD and diabetes mellitus.Unanimity1st round5 DCompiled by authorsReferenceMetformin, if tolerated and not contraindicated, is the first drug of choice for patients with COPD and DM.Consensus(91.3%)1st round4 CCompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CcnVpanN0ZW5zPC9BdXRob3I+PFllYXI+MjAwODwvWWVh

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ADDIN EN.CITE.DATA 33,34COPD in the presence of DM should be treated according to standard clinical practice guideline recommendations, since there is no direct evidence that these patients need to be treated differently, in spite of increasing dyspnea or a greater predisposition to exacerbations that might be a result of this comorbidity.Consensus(95.7%)1st round5 DCompiled by authorsReference: ADDIN EN.CITE <EndNote><Cite><RecNum>3774</RecNum><IDText>From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: face="superscript">35</style></DisplayText><record><rec-number>3774</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552034988">3774</key></foreign-keys><ref-type name="Generic">13</ref-type><contributors></contributors><titles><title>From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: ) DYSLIPIDEMIAConsequences of dyslipidemia in COPD patientAvailable evidence on the role of dyslipidemia in COPD is still insufficient to establish specific findings on the consequences of this comorbidity in these patients.Consensus(82.6%)1st round-Expert opinionTreatment of patients with COPD and dyslipidemiaOverall, it seems that COPD patients who benefit most from treatment with statins are those who have concomitant cardiovascular disease.Consensus(95.7%)1st round1Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5aaGFuZzwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 36The clinical benefit of statins in COPD patients who do not have other risk factors for cardiovascular disease is not currently established.Consensus(87.0%)1st round--All patients with COPD and cardiovascular disease should receive statins according to clinical practice guideline recommendations.Unanimity1st round5 DCompiled by authorsExpert opinionCOPD patients should receive the treatment recommended in the clinical practice guidelines regardless of whether they have concomitant dyslipidemia or not, and vice versa.Consensus (95.7%)1st round5 DCompiled by authorsExpert opinionSupplementary table 3. Conclusions and recommendations on the clinical consequences and treatment of cardiovascular comorbidities in COPD patientsConclusions (C) and Recommendations (R) Final resultsLevel of evidence (LE)/ Grade of evidence (GR)SourceA) HEART FAILURE (HF)Consequences of HF in COPDHealth-related quality of life is worse in patients with COPD who have concomitant HF.Unanimity1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWU8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxSZWNO

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ADDIN EN.CITE.DATA 37,38HF worsens the prognosis of patients with COPD, in terms of new exacerbations, hospitalizations, and death rates.Unanimity1st round2References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbG1hZ3JvPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48

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ADDIN EN.CITE.DATA 39-42Raised natriuretic peptide levels are associated with increased mortality in patients with COPD.Consensus(82.6%)1st round1Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXZhc2luaTwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+

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ADDIN EN.CITE.DATA 43Since the prevalence of HF is higher in patients with COPD, and confers a worse prognosis, ruling out the presence of HF is recommended.Unanimity1st round2 CCompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbG1hZ3JvPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48

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ADDIN EN.CITE.DATA 39-42,44-47If HF is suspected in patients with COPD, natriuretic peptide levels should be determined.Consensus(95.2%)2nd round1 BCompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXZhc2luaTwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+

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ADDIN EN.CITE.DATA 43,48-51Treatment of patients with COPD and HFDrugs used for the treatment of HF are safe in patients with COPD.Unanimity1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb3ZlcnNpPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48

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b3RlPn==

ADDIN EN.CITE.DATA 52-54Long-acting bronchodilators and inhaled corticosteroids are safe in patients with HF.Unanimity1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HcnVwbyBkZSBUcmFiYWpvIGRlIEdlc0VQT0M8L0F1dGhv

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ADDIN EN.CITE.DATA 14,55-57In COPD, if beta-blockers are indicated, the use of cardioselective drugs is preferred.Unanimity1st round1 BCompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYWtlcjwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 52-54,58COPD patients should receive the treatment recommended in the guidelines regardless of whether they have concomitant HF or not, and vice versa.Unanimity(90.5%)2nd round5 DCompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaXJhdml0bGxlczwvQXV0aG9yPjxZZWFyPjIwMTc8L1ll

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ADDIN EN.CITE.DATA 55,59B) ISCHEMIC HEART DISEASE (IHD)Consequences of IHD in COPDThe presence of IHD worsens health-related quality of life in patients with COPD.Unanimity1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb3ZlcnNpPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48

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ADDIN EN.CITE.DATA 52,60-62IHD increases the risk of hospitalization and mortality in patients with COPD.Consensus(95.7%)1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbG1hZ3JvPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48

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ADDIN EN.CITE.DATA 39,63,64In all patients with COPD, the possibility of IHD should be ruled out, since this comorbidity worsens patient prognosis.Consensus(81.0%)2nd round1 ACompiled by authorsReference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb3ZlcnNpPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48

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ADDIN EN.CITE.DATA 52Treatment of patients with COPD and ischemic heart diseaseThe treatment of COPD is safe in patients with IHD.Consensus(95.7%)1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5YaWE8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxSZWNO

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ADDIN EN.CITE.DATA 65-68The treatment of COPD is associated with a decrease in cardiovascular mortality in epidemiological studies and in some clinical trials, although this could not be demonstrated in studies where mortality was the main variable.Consensus(87.0%)1st round2References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5WZXN0Ym88L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 56,69-75Cardiovascular drugs are safe in patients with COPD.Unanimity1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db2lybzwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 72,76-79Since the safety and effectiveness of drugs for IHD and COPD are not modified in patients with both diseases, the presence of IHD does not require a modification of the COPD treatment recommended in the clinical practice guidelines, and vice versa.Consensus(91.3%)1st round2 BCompiled by authorsReferences: ADDIN EN.CITE <EndNote><Cite><Author>Grupo de Trabajo de GesEPOC</Author><Year>2017</Year><RecNum>3587</RecNum><IDText>Guía de Práctica Clínica para el Diagnóstico y Tratamiento de Pacientes con Enfermedad Pulmonar Obstructiva Crónica (EPOC) – Guía Espa?ola de la EPOC (GesEPOC). Versión 2017</IDText><DisplayText><style face="superscript">14,35</style></DisplayText><record><rec-number>3587</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552034924">3587</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Grupo de Trabajo de GesEPOC,</author></authors></contributors><titles><title>Guía de Práctica Clínica para el Diagnóstico y Tratamiento de Pacientes con Enfermedad Pulmonar Obstructiva Crónica (EPOC) – Guía Espa?ola de la EPOC (GesEPOC). Versión 2017</title><secondary-title>Arch Bronconeumol</secondary-title></titles><periodical><full-title>Archivos de Bronconeumologia</full-title><abbr-1>Arch. Bronconeumol.</abbr-1><abbr-2>Arch Bronconeumol</abbr-2></periodical><pages>2-64</pages><volume>53</volume><number>Suppl 1</number><dates><year>2017</year></dates><urls></urls></record></Cite><Cite><RecNum>3774</RecNum><IDText>From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552034988">3774</key></foreign-keys><ref-type name="Generic">13</ref-type><contributors></contributors><titles><title>From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: ) PERIPHERAL ARTERY DISEASE (PAD)Consequences of PAD in COPDThe presence of PAD in COPD patients is associated with a poorer quality of life and reduced exercise tolerance compared with COPD patients without PAD.Unanimity1st round1Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib3ViZW4tV2lsa2U8L0F1dGhvcj48WWVhcj4yMDE3PC9Z

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ADDIN EN.CITE.DATA 80Mortality of COPD patients is increased in the presence of PAD.Consensus(95.7%)1st round3References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbG1hZ3JvPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48

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ADDIN EN.CITE.DATA 39,81Due to lack of evidence, no conclusion can be made regarding the effect of PAD on the disease course of COPD patients.Consensus(87.0%)1st round--The presence of PAD should be ruled out in COPD patients because it is associated with worse quality of life, lower exercise tolerance, and increased mortality.Consensus(91.3%)1st round1Compiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYXNjaGtpPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48

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ADDIN EN.CITE.DATA 39,80,81Treatment of COPD patients with PADThe treatment of COPD is safe in patients with PAD.Unanimity1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gR2VzdGVsPC9BdXRob3I+PFllYXI+MjAwOTwvWWVh

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ADDIN EN.CITE.DATA 82,83Lifestyle and dietary measures and abstinence from smoking are recommended for both PAD and COPD.Unanimity1st round1Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HZXJoYXJkLUhlcm1hbjwvQXV0aG9yPjxZZWFyPjIwMTc8

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AG==

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AG==

ADDIN EN.CITE.DATA 84The use of statins and beta-blockers in patients with PAD and concomitant COPD is safe.Consensus(95.7%)1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gR2VzdGVsPC9BdXRob3I+PFllYXI+MjAwOTwvWWVh

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ADDIN EN.CITE.DATA 82,83Patients with COPD and PAD should be treated in accordance with standard clinical practice guideline recommendations, since there is no evidence that the presence of PAD alters the treatment for COPD.Unanimity1st round5 DCompiled by authorsExpert opinionD) ATRIAL FIBRILLATION (AF)Consequences of AF in COPDAF worsens quality of life in COPD patients.Unanimity1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NaXlhemFraTwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+

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ADDIN EN.CITE.DATA 85AF increases the risk of hospitalization and mortality in patients with COPD.Unanimity1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbG1hZ3JvPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48

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dGU+

ADDIN EN.CITE.DATA 39,86-89AF can cause COPD exacerbation.Consensus(85.7%)2nd round1Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5PbmlzaGk8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 90Treatment of patients with COPD and AFInhaled bronchodilators at standard doses are safe in patients with COPD and AF.Consensus(91.3%)1st round1References: ADDIN EN.CITE <EndNote><Cite><Author>Grupo de Trabajo de GesEPOC</Author><Year>2017</Year><RecNum>3587</RecNum><IDText>Guía de Práctica Clínica para el Diagnóstico y Tratamiento de Pacientes con Enfermedad Pulmonar Obstructiva Crónica (EPOC) – Guía Espa?ola de la EPOC (GesEPOC). Versión 2017</IDText><DisplayText><style face="superscript">14,35</style></DisplayText><record><rec-number>3587</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552034924">3587</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Grupo de Trabajo de GesEPOC,</author></authors></contributors><titles><title>Guía de Práctica Clínica para el Diagnóstico y Tratamiento de Pacientes con Enfermedad Pulmonar Obstructiva Crónica (EPOC) – Guía Espa?ola de la EPOC (GesEPOC). Versión 2017</title><secondary-title>Arch Bronconeumol</secondary-title></titles><periodical><full-title>Archivos de Bronconeumologia</full-title><abbr-1>Arch. Bronconeumol.</abbr-1><abbr-2>Arch Bronconeumol</abbr-2></periodical><pages>2-64</pages><volume>53</volume><number>Suppl 1</number><dates><year>2017</year></dates><urls></urls></record></Cite><Cite><RecNum>3774</RecNum><IDText>From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552034988">3774</key></foreign-keys><ref-type name="Generic">13</ref-type><contributors></contributors><titles><title>From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: treatment of AF does not differ in patients with concomitant COPD.Consensus (91.3%)1st round5References: ADDIN EN.CITE <EndNote><Cite><Author>Grupo de Trabajo de GesEPOC</Author><Year>2017</Year><RecNum>3587</RecNum><IDText>Guía de Práctica Clínica para el Diagnóstico y Tratamiento de Pacientes con Enfermedad Pulmonar Obstructiva Crónica (EPOC) – Guía Espa?ola de la EPOC (GesEPOC). Versión 2017</IDText><DisplayText><style face="superscript">14,35</style></DisplayText><record><rec-number>3587</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552034924">3587</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Grupo de Trabajo de GesEPOC,</author></authors></contributors><titles><title>Guía de Práctica Clínica para el Diagnóstico y Tratamiento de Pacientes con Enfermedad Pulmonar Obstructiva Crónica (EPOC) – Guía Espa?ola de la EPOC (GesEPOC). Versión 2017</title><secondary-title>Arch Bronconeumol</secondary-title></titles><periodical><full-title>Archivos de Bronconeumologia</full-title><abbr-1>Arch. Bronconeumol.</abbr-1><abbr-2>Arch Bronconeumol</abbr-2></periodical><pages>2-64</pages><volume>53</volume><number>Suppl 1</number><dates><year>2017</year></dates><urls></urls></record></Cite><Cite><RecNum>3774</RecNum><IDText>From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552034988">3774</key></foreign-keys><ref-type name="Generic">13</ref-type><contributors></contributors><titles><title>From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: and inhaled corticosteroids should be used at standard doses in patients with COPD and AF.Consensus(82.6%)1st round5 DCompiled by authorsReference:PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Hb3VkaXM8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 91High doses of short acting beta agosnists and theophylline should be avoided, as these can trigger AF or worsen control of the ventricular rate.Consensus(95.7%)1st round1 ACompiled by authorsReference:PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdWVydGE8L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 92The use of beta-blockers in COPD exacerbations is not contraindicated, although cardioselective agents are always recommended.Unanimity1st round1 AAdopted from ADDIN EN.CITE <EndNote><Cite><Author>Díez-Manglano</Author><Year>2014</Year><RecNum>39592</RecNum><IDText>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</IDText><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>39592</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552094241">39592</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Díez-Manglano, J.</author><author>López-García, F.</author></authors></contributors><titles><title>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</title><secondary-title>Sociedad Espa?ola de Medicina Interna (SEMI) y Elsevier SL</secondary-title></titles><pages>1-259</pages><dates><year>2014</year></dates><isbn>978-84-7592-7626</isbn><urls><related-urls><url><style face="underline" font="default" size="100%"> face="normal" font="default" size="100%">.</style></url></related-urls></urls></record></Cite></EndNote>10 References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GdXN0ZXI8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 35,93Supplementary table 4. Conclusions and recommendations on the clinical consequences and treatment of neuropsychiatric comorbidities in COPD patientsConclusions (C) and Recommendations (R)Final resultsLevel of evidence (LE)/ Grade of evidence (GR)SourceA) ANXIETYConsequences of anxiety in COPDIn patients with COPD, the presence of anxiety is associated with a worse quality of life, greater frequency of exacerbations, and reduced survival.Consensus(91.3%)1st round2References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LdW5pazwvQXV0aG9yPjxZZWFyPjIwMDU8L1llYXI+PFJl

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L0VuZE5vdGU+

ADDIN EN.CITE.DATA 94-99The presence of anxiety is associated with worse therapeutic adherence, greater failure of pulmonary rehabilitation programs or smoking cessation, and higher healthcare costs in general.Unanimity1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XaWxsZ29zczwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+

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ADDIN EN.CITE.DATA 98,100-105The anxiety status of COPD patients should be assessed, due to its high impact in terms of quality of life, exacerbations, hospitalizations, and survival.Unanimity1st round2 BCompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BdGxhbnRpczwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+

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L0VuZE5vdGU+

ADDIN EN.CITE.DATA 94-99Anxiety assessment scales and quality of life questionnaires must be used in these patients.Consensus(82.6%)1st round3 CCompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ew61lei1NYW5nbGFubzwvQXV0aG9yPjxZZWFyPjIwMTQ8

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ADDIN EN.CITE.DATA 10,96,99,106Treatment of patients with COPD and anxietyC3The published literature on the treatment of anxiety in patients with COPD is limited but points to the need for a multidisciplinary approach and the implementation of personalized therapeutic strategies to improve the treatment and prognosis of these patients.Unanimity1st round5Expert opinionAntidepressants alter patients’ perception of some symptoms, such as dyspnea, and improve quality of life.Consensus(95.7%)1st round2Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DYXZhaWxsZXM8L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy

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ADDIN EN.CITE.DATA 107Exercise can have positive effects on the psychological health of all COPD patients, including those with low or moderate levels of anxiety.Unanimity1st round3Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EdXJzdW5vZ2x1PC9BdXRob3I+PFllYXI+MjAxNjwvWWVh

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ADDIN EN.CITE.DATA 108The use of relaxation techniques in patients with COPD who have anxiety could have a beneficial effect on lung function and decrease anxiety levels.Consensus(91.3%)1st round4Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Wb2xwYXRvPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48

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ADDIN EN.CITE.DATA 109In patients with COPD and associated anxiety, the use of SSRIs is recommended, unless contraindicated.Consensus(95.7%)1st round2 AAdapted from ADDIN EN.CITE <EndNote><Cite><Year>2018</Year><RecNum>39707</RecNum><IDText>Depression in adults: recognition and management | Guidance and guidelines | NICE</IDText><DisplayText><style face="superscript">110</style></DisplayText><record><rec-number>39707</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552094570">39707</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors></contributors><titles><title>Depression in adults: recognition and management | Guidance and guidelines | NICE</title></titles><keywords><keyword>Health, well-being and care</keyword></keywords><dates><year>2018</year></dates><publisher>NICE</publisher><urls><related-urls><url> contraindicated, patients with COPD and anxiety should be advised to participate in a respiratory rehabilitation program, particularly programs based on physical exercise.Consensus(91.3%)1st round3 CCompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbGV4b3BvdWxvczwvQXV0aG9yPjxZZWFyPjIwMDY8L1ll

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ADDIN EN.CITE.DATA 111-113The presence of drug-drug interactions between anti-anxiety medications and theophylline must be investigated.Consensus(91.3%)1st round1 BAdapted from ADDIN EN.CITE <EndNote><Cite><Author>Díez-Manglano</Author><Year>2014</Year><RecNum>39592</RecNum><IDText>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</IDText><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>39592</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552094241">39592</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Díez-Manglano, J.</author><author>López-García, F.</author></authors></contributors><titles><title>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</title><secondary-title>Sociedad Espa?ola de Medicina Interna (SEMI) y Elsevier SL</secondary-title></titles><pages>1-259</pages><dates><year>2014</year></dates><isbn>978-84-7592-7626</isbn><urls><related-urls><url><style face="underline" font="default" size="100%"> face="normal" font="default" size="100%">.</style></url></related-urls></urls></record></Cite></EndNote>10B) INSOMNIAConsequences of insomnia in COPDQuality of sleep in COPD patients is often poor. This not only affects quality of life but is also a risk factor for exacerbations, emergency visits, and increased all-cause mortality.Unanimity1st round2References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OdW5lczwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 114-116COPD patients should be asked about their quality of sleep, due to the potential deleterious effects of poor quality of sleep on the course of COPD.Unanimity1st round2 CCompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OdW5lczwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 114-116Treatment of patients with COPD and insomniaThe drugs most widely used in the treatment of insomnia are hypnotics and benzodiazepines, but these have significant respiratory adverse effects that need to be taken into account in the management of COPD and insomnia.Consensus(91.3%)1st round3References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Wb3pvcmlzPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48

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Pn==

ADDIN EN.CITE.DATA 117-119Long-acting bronchodilators are safe in terms of quality of sleep.Consensus(91.3%)1st round3References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY05pY2hvbGFzPC9BdXRob3I+PFllYXI+MjAwNDwvWWVh

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PjwvRW5kTm90ZT4A

ADDIN EN.CITE.DATA 120,121Indacaterol appears to reduce night-time awakenings caused by dyspnea, compared with placebo, tiotropium, and salmeterol.Consensus(81%)2nd round3References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb25vaHVlPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48

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ADDIN EN.CITE.DATA 122,123The dose of benzodiazepines should be adjusted in patients receiving theophylline, as their effects are reduced in these patients. It should be determined if the patient is using St. John's wort concomitantly with theophylline, due to the risk of interactions.Consensus(82.6%)1st round3 CAdapted from ADDIN EN.CITE <EndNote><Cite><Author>Díez-Manglano</Author><Year>2014</Year><RecNum>39592</RecNum><IDText>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</IDText><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>39592</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552094241">39592</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Díez-Manglano, J.</author><author>López-García, F.</author></authors></contributors><titles><title>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</title><secondary-title>Sociedad Espa?ola de Medicina Interna (SEMI) y Elsevier SL</secondary-title></titles><pages>1-259</pages><dates><year>2014</year></dates><isbn>978-84-7592-7626</isbn><urls><related-urls><url><style face="underline" font="default" size="100%"> face="normal" font="default" size="100%">.</style></url></related-urls></urls></record></Cite></EndNote>10Insomnia in COPD patients must be treated.Unanimity1st round5 DCompiled by authorsExpert opinionCOPD patients should receive the treatment recommended in clinical practice guidelines regardless of whether they have concomitant insomnia or not.Unanimity1st round5 DCompiled by authorsExpert opinionC) DEPRESSIONConsequences of depression in COPDPatients with COPD and depression have a worse quality of life, more exacerbations, and higher mortality.Consensus(95.7%)1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdWJlcjwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 98,99,124,125Patients with COPD and depression have more functional decline and reduced exercise tolerance.Consensus(100%)1st round3References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OZzwvQXV0aG9yPjxZZWFyPjIwMDk8L1llYXI+PFJlY051

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ADDIN EN.CITE.DATA 128Given the impact of depression on progress and survival, the existence of depression in patients with COPD should be ruled out at frequent intervals.Unanimity1st round5 DCompiled by authorsExpert opinionTreatment of patients with COPD and depressionIn patients with COPD, the treatment of depression is associated with better health outcomes (fewer emergency department visits, fewer hospitalizations, less dyspnea, and better quality of life).Consensus(95.7%)1st round3References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FaXNlcjwvQXV0aG9yPjxZZWFyPjIwMDU8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 129,130Antidepressants are safe in patients with COPD.Unanimity1st round2Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Zb2hhbm5lczwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+

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ADDIN EN.CITE.DATA 131COPD patients should receive the treatment recommended in the clinical practice guidelines regardless of whether they have depression or not.Consensus(95.7%)1st round5 DAdapted from ADDIN EN.CITE <EndNote><Cite><Author>Díez-Manglano</Author><Year>2014</Year><RecNum>39592</RecNum><IDText>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</IDText><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>39592</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552094241">39592</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Díez-Manglano, J.</author><author>López-García, F.</author></authors></contributors><titles><title>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</title><secondary-title>Sociedad Espa?ola de Medicina Interna (SEMI) y Elsevier SL</secondary-title></titles><pages>1-259</pages><dates><year>2014</year></dates><isbn>978-84-7592-7626</isbn><urls><related-urls><url><style face="underline" font="default" size="100%"> face="normal" font="default" size="100%">.</style></url></related-urls></urls></record></Cite></EndNote>10Patients with COPD and depression should receive psychological therapy, and pharmacological treatment if there is no improvement.Unanimity1st round1 ACompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db3ZlbnRyeTwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+

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ADDIN EN.CITE.DATA 132,133Patients with COPD and depression should be referred for respiratory rehabilitation.Consensus(87%)1st round1 AAdapted from PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Uc2VsZWJpczwvQXV0aG9yPjxZZWFyPjIwMTY8L1llYXI+

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ADDIN EN.CITE.DATA 134Selective serotonin reuptake inhibitors are the antidepressants of choice in COPD patients.Unanimity1st round1 ACompiled by authorsReference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Gcml0enNjaGU8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy

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ADDIN EN.CITE.DATA 135Fluvoxamine and St. John's wort must not be used in combination to treat depression in COPD patients who are receiving roflumilast or theophylline. Consensus(82.65)1st round5 DAdapted from ADDIN EN.CITE <EndNote><Cite><Author>Díez-Manglano</Author><Year>2014</Year><RecNum>39592</RecNum><IDText>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</IDText><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>39592</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552094241">39592</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Díez-Manglano, J.</author><author>López-García, F.</author></authors></contributors><titles><title>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</title><secondary-title>Sociedad Espa?ola de Medicina Interna (SEMI) y Elsevier SL</secondary-title></titles><pages>1-259</pages><dates><year>2014</year></dates><isbn>978-84-7592-7626</isbn><urls><related-urls><url><style face="underline" font="default" size="100%"> face="normal" font="default" size="100%">.</style></url></related-urls></urls></record></Cite></EndNote>10Anticholinergic symptoms should be monitored when anticholinergic bronchodilators are combined with monoamine oxidase inhibitors or tricyclic antidepressants.Unanimity1st round5 DCompiled by authorsExpert opinionD) COGNITIVE DETERIORATIONConsequences of cognitive dysfunction in COPDPatients with COPD and dementia have a higher risk of hospital admission and longer hospital stays.Unanimity1st round3References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGFuZzwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 136,137The presence of cognitive impairment could be an independent risk factor for long-term mortality in COPD patients.Unanimity1st round3References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGFuZzwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 39,136,138The lack of evidence makes it impossible to conclude if the rate of exacerbations or quality of life in COPD patients are affected by the presence of cognitive impairment.Consensus(85.7%)2nd round--Due to the its impact on progress and survival, the existence of cognitive impairment in patients with COPD should be ruled out.Consensus(91.3%)1st round5DCompiled by authorsExpert opinionTreatment of patients with COPD and cognitive impairmentDrugs used for the treatment of cognitive impairment (acetylcholinesterase inhibitors) are safe and do not affect the standard treatment of COPD.Unanimity1st round3Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TdGVwaGVuc29uPC9BdXRob3I+PFllYXI+MjAxMjwvWWVh

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b3RlPn==

ADDIN EN.CITE.DATA 139Pulmonary rehabilitation programs partially improve cognitive function in patients with COPD.Consensus(81%)2nd round2References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QZXJlaXJhPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48

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ADDIN EN.CITE.DATA 140-142COPD patients should receive the treatment recommended in the clinical practice guidelines regardless of whether they have cognitive impairment or not.Unanimity1st round5 DCompiled by authorsExpert opinionPatients with COPD and cognitive impairment who have hypoxemia benefit from treatment with oxygen therapy to delay the progress of cognitive impairment.Consensus(81%)2nd round3 BCompiled by authorsReference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UaGFrdXI8L0F1dGhvcj48WWVhcj4yMDEwPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 143In the event that cognitive impairment prevents the use of inhalation devices, COPD patients will use spacers or nebulization devices.Unanimity1st round5 DCompiled by authorsExpert opinionIn patients with COPD and cognitive impairment, the use of inhalation devices will be supervised, and caregivers will also be instructed in their use.Consensus(95.7%)1st round5 DCompiled by authorsExpert opinionSupplementary table 5. Conclusions and recommendations on the clinical consequences and treatment of other comorbidities in COPD patientsConclusions (C) and Recommendations (R)Final resultsLevel of evidence (LE)/Grade of evidence (GR)SourceA) PAINConsequences of pain in COPDPain in COPD patients can occur at any disease stage and leads to a deterioration in quality of life.Unanimity1st round2References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Mb2huZTwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 144-146No studies have evaluated the possible relationship between pain and an increased likelihood of exacerbation or hospital admission in COPD patients, and no association between the presence of pain and a lower survival has been detected in these patients.Consensus(81%)2nd round--Given that the pain affects quality of life and may be associated with a greater presence of fatigue or dyspnea, pain quantification scales are useful for the evaluation of pain and for assessing response to treatment.Consensus(87%)1st round5 DCompiled by authors Expert opinionTreatment of patients with COPD and painThe use of opioids at appropriate doses does not increase the risk of respiratory depression in COPD patients.Consensus(85.7%)2nd round1References:PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Fa3N0cm9tPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48

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ADDIN EN.CITE.DATA 147-149Treatments for COPD do not affect treatment for pain in any way.Consensus(87%)1st round--If opioid treatment is needed in patients with COPD and pain, it should begin at 50% of the dose, and then gradually escalated, in order to achieve an adequate level of analgesia, especially in older patients.Consensus(87%)1st round5 DAdapted from ADDIN EN.CITE <EndNote><Cite><Author>Díez-Manglano</Author><Year>2014</Year><RecNum>39592</RecNum><IDText>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</IDText><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>39592</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552094241">39592</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Díez-Manglano, J.</author><author>López-García, F.</author></authors></contributors><titles><title>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</title><secondary-title>Sociedad Espa?ola de Medicina Interna (SEMI) y Elsevier SL</secondary-title></titles><pages>1-259</pages><dates><year>2014</year></dates><isbn>978-84-7592-7626</isbn><urls><related-urls><url><style face="underline" font="default" size="100%"> face="normal" font="default" size="100%">.</style></url></related-urls></urls></record></Cite></EndNote>10 Expert opinionIncreasing the dose or frequency of drugs used in the treatment of COPD to alleviate a perceived sensation of dyspnea due to pain is not recommended, since these drugs do not improve analgesia in these patients, but side effects and drug interactions may increase.Consensus(87%)1st round5 DCompiled by authorsExpert opinionAppropriate analgesia not only reduces the perception of pain but in some cases can also improve feelings of fatigue or dyspnea in COPD patients, so attempts should be made to achieve the best possible level of analgesia.Unanimity1st round5 DCompiled by authorsExpert opinionB) ANEMIAConsequences of anemia in COPDIn COPD patients, anemia is associated with a worse quality of life, reduced exercise tolerance, and dyspnea.Unanimity1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db3RlPC9BdXRob3I+PFllYXI+MjAwNzwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 150,151In COPD, anemia is associated with more hospitalizations and exacerbations.Consensus(95.7%)1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYXJiYTwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 151-153Patients with COPD and anemia have a higher rate of hospital readmission.Consensus(95.7%)1st round1Reference: ADDIN EN.CITE <EndNote><Cite><Author>Vasquez</Author><Year>2016</Year><RecNum>38744</RecNum><IDText>Anemia in Chronic Obstructive Pulmonary Disease and the Potential Role of Iron Deficiency</IDText><DisplayText><style face="superscript">151</style></DisplayText><record><rec-number>38744</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552091583">38744</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Vasquez, A.</author><author>Logomarsino, J. V.</author></authors></contributors><auth-address>a Central Michigan University , Mount Pleasant , Michigan , USA.</auth-address><titles><title>Anemia in Chronic Obstructive Pulmonary Disease and the Potential Role of Iron Deficiency</title><secondary-title>Copd</secondary-title><alt-title>Copd</alt-title></titles><pages>100-9</pages><volume>13</volume><number>1</number><edition>2015/09/30</edition><keywords><keyword>Anemia/complications/physiopathology</keyword><keyword>Anemia, Iron-Deficiency/complications/drug therapy/*physiopathology</keyword><keyword>Dietary Supplements</keyword><keyword>Humans</keyword><keyword>Iron/therapeutic use</keyword><keyword>Pulmonary Disease, Chronic Obstructive/complications/*physiopathology</keyword><keyword>health care cost</keyword><keyword>inflammation</keyword><keyword>mortality</keyword><keyword>quality of life</keyword></keywords><dates><year>2016</year></dates><isbn>1541-2563</isbn><accession-num>26418826</accession-num><urls><related-urls><url> with COPD and anemia have a higher mortality rate during hospital admission, in the short and long term.Unanimity1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYWxwZXJuPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48

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ADDIN EN.CITE.DATA 150,151,153-157Due to its impact on quality of life, hospitalizations, and survival, the presence of anemia and its etiology should be investigated in all patients with COPD.Consensus(95.7%)1st round5 DCompiled by authorsExpert opinionIn patients with COPD and anemia, the etiological treatment of anemia is recommended.Unanimity1st round5 DCompiled by authorsExpert opinionC) OSTEOPOROSISConsequences of osteoporosis in COPDPatients with COPD and osteoporosis have a worse quality of life, more exacerbations, and higher mortality.Consensus(87%)1st round2References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MZWU8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxSZWNO

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ADDIN EN.CITE.DATA 158,159Patients with COPD and osteoporosis or vertebral fractures have more exacerbations, more hospitalizations, and longer average lengths of stay.Consensus(95.7%)1st round2References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYWxpbm92c2NoaTwvQXV0aG9yPjxZZWFyPjIwMTQ8L1ll

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ADDIN EN.CITE.DATA 160-162Patients with COPD and vertebral fracture have greater 2-year mortality.Consensus(95.7%)1st round2Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QYXNjdWFsLUd1YXJkaWE8L0F1dGhvcj48WWVhcj4yMDE3

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ADDIN EN.CITE.DATA 162Patients with COPD and osteoporosis show less improvement in exercise tolerance after pulmonary rehabilitation programs than patients with other comorbidities.Consensus(82.6%)1st round1Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib3JuaWt4PC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48

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ADDIN EN.CITE.DATA 163Due to the impact of osteoporosis on progress and survival, the existence of osteoporosis should be ruled out in COPD patients.Consensus(87%)1st round5 DCompiled by authorsExpert opinionDue to the impact of osteoporosis on progress and survival, it is recommended that the existence of vertebral fractures in COPD patients is always ruled out with the simple procedure of performing a lateral chest X-ray.Consensus(91.3%)1st round5 DCompiled by authorsExpert opinionTreatment of patients with COPD and osteoporosisSystemic corticosteroids used for the treatment of COPD exacerbations increase the risk of osteoporosis.Unanimity1st round1Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbWljaGU8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 165,166Bisphosphonates are useful for the treatment of corticosteroid-induced osteoporosis.Consensus(95.7%)1st round1Reference: ADDIN EN.CITE <EndNote><Cite><Author>Allen</Author><Year>2016</Year><RecNum>38782</RecNum><IDText>Bisphosphonates for steroid-induced osteoporosis</IDText><DisplayText><style face="superscript">167</style></DisplayText><record><rec-number>38782</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552091697">38782</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Allen, C. S.</author><author>Yeung, J. H.</author><author>Vandermeer, B.</author><author>Homik, J.</author></authors></contributors><auth-address>Department of Rheumatology, University of Alberta, 562 Heritage Medical Research Centre, Edmonton, AB, Canada, T6G 2S2.</auth-address><titles><title>Bisphosphonates for steroid-induced osteoporosis</title><secondary-title>Cochrane Database Syst Rev</secondary-title><alt-title>The Cochrane database of systematic reviews</alt-title></titles><periodical><full-title>Cochrane Database of Systematic Reviews</full-title><abbr-1>Cochrane Database Syst. Rev.</abbr-1><abbr-2>Cochrane Database Syst Rev</abbr-2></periodical><pages>Cd001347</pages><volume>10</volume><edition>2016/11/02</edition><keywords><keyword>Adult</keyword><keyword>Bone Density Conservation Agents/*therapeutic use</keyword><keyword>Diphosphonates/*therapeutic use</keyword><keyword>Glucocorticoids/*adverse effects</keyword><keyword>Humans</keyword><keyword>Osteoporosis/*chemically induced/*prevention &amp; control</keyword><keyword>Randomized Controlled Trials as Topic</keyword><keyword>Spinal Fractures/*prevention &amp; control</keyword></keywords><dates><year>2016</year><pub-dates><date>Oct 5</date></pub-dates></dates><isbn>1361-6137</isbn><accession-num>27706804</accession-num><urls><related-urls><url> rehabilitation programs improve exercise tolerance in patients with COPD and osteoporosis.Consensus(95.7%)1st round1Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib3JuaWt4PC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48

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ADDIN EN.CITE.DATA 163Osteoporosis in patients with COPD should be treated according to standard clinical practice guideline recommendations.Unanimity1st round5 DCompiled by authorsExpert opinionIn patients with COPD and osteoporosis, inhaled corticosteroids must be administered at the lowest effective dose possible.Consensus(91.3%)1st round1 AReference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYXR0aXNoZW50PC9BdXRob3I+PFllYXI+MjAxNDwvWWVh

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ADDIN EN.CITE.DATA 164Patients with COPD and osteoporosis should be referred for rehabilitation.Consensus(82.6%)1st round1 AAdapted from PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib3JuaWt4PC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48

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ADDIN EN.CITE.DATA 163D) GASTROESOPHAGEAL REFLUX DISEASE (GERD)Consequences of GERD in COPD The presence of reflux symptoms in patients with COPD is associated with an increased frequency and severity of exacerbations, and a poorer quality of life.Consensus(87%)1st round2References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IdXJzdDwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 168-173The impact of GERD on mortality in COPD patients is not well established.Consensus(87%)1st round-References: PEVuZE5vdGU+PENpdGU+PFJlY051bT4zOTAxOTwvUmVjTnVtPjxJRFRleHQ+TMOzcGV6IEdhcmPD

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ADDIN EN.CITE.DATA 174-177The presence of symptoms of GERD should be ruled out in patients with COPD.Consensus(91.3%)1st round5 DCompiled by authorsExpert opinionTreatment of patients with COPD and GERDCOPD treatments are safe in patients with GERD.Consensus(95.7%)1st round5Reference: ADDIN EN.CITE <EndNote><Cite><RecNum>39019</RecNum><IDText>López García F, Pasquau Lia?o F. Enfermedades digestivas y enfermedad pulmonar obstructiva crónica. Med Clin (Barc). 2010;11:13-6.</IDText><DisplayText><style face="superscript">174</style></DisplayText><record><rec-number>39019</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552092391">39019</key></foreign-keys><ref-type name="Generic">13</ref-type><contributors></contributors><titles><title>López García F, Pasquau Lia?o F. Enfermedades digestivas y enfermedad pulmonar obstructiva crónica. Med Clin (Barc). 2010;11:13-6.</title></titles><dates></dates><urls></urls></record></Cite></EndNote>174The use of high-dose omeprazole in patients with GERD and COPD does not improve airway hyperresponsiveness or lung function.Consensus(82.6%)1st round5Reference: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qb2U8L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFyPjxSZWNO

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ADDIN EN.CITE.DATA 178Studies are needed to determine the possible benefit of drugs used in GERD in reducing the incidence of exacerbations in COPD patients.Consensus(95.7%)1st round5Expert opinionThe treatment of GERD in COPD patients should follow clinical practice guidelines recommendations for GERD.Consensus(95.7%)1st round5 DCompiled by authorsExpert opinionE) THROMBOEMBOLIC DISEASEConsequences of thromboembolic disease in COPDSymptoms of pulmonary embolism can be confused with those of a COPD exacerbation.Consensus(95.7%)1st round5Expert opinionPatients with COPD exacerbation and concomitant thromboembolic disease are more often admitted to the ICU and present a worse prognosis.Unanimity1st round2References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HdW5lbjwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 179-182Treatment of patients with COPD and thromboembolic diseaseProphylaxis with low molecular weight heparins is recommended in hospitalized COPD patients while they are bedridden. An alternative treatment is fondaparinux at a dose of 2.5 mg/day. Prophylaxis with low-dose low molecular weight heparins is not recommended.Unanimity1st round3 CCompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GcmFpc3NlPC9BdXRob3I+PFllYXI+MjAwMDwvWWVhcj48

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PC9FbmROb3RlPgB=

ADDIN EN.CITE.DATA 183In patients in whom anticoagulation is contraindicated, the use of physical measures, such as graduated compression stockings or intermittent pneumatic compression, is recommended.Unanimity1st round3 CCompiled by authorsReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GcmFpc3NlPC9BdXRob3I+PFllYXI+MjAwMDwvWWVhcj48

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PC9FbmROb3RlPgB=

ADDIN EN.CITE.DATA 183Deep vein thrombosis and/or pulmonary thromboembolism in COPD patients should be treated according to standard clinical practice guideline recommendations.Unanimity1st round5 DCompiled by authorsExpert opinionCOPD patients should receive the treatment recommended in the clinical practice guidelines regardless of whether they have deep vein thrombosis or not.Unanimity1st round5 DCompiled by authorsExpert opinionF) CHRONIC KIDNEY DISEASE (CKD)Consequences of CKD in COPDPatients with COPD and CKD have a higher mortality rate.Consensus(95.7%)1st round1References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TaW5nYW5heWFnYW08L0F1dGhvcj48WWVhcj4yMDEzPC9Z

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ADDIN EN.CITE.DATA 184-188Given the high prevalence of occult chronic kidney disease in COPD, glomerular filtration rate must always be estimated using MDRD (Modification of Diet in Renal Disease) or CKD-EPI equationsUnanimity1st round1 ACompiled by authorsReference: ADDIN EN.CITE <EndNote><Cite><Author>Rashiq</Author><Year>2009</Year><IDText>Factors associated with chronic noncancer pain in the Canadian population</IDText><DisplayText><style face="superscript">189</style></DisplayText><record><dates><pub-dates><date>Nov-Dec</date></pub-dates><year>2009</year></dates><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Association</keyword><keyword>Canada/epidemiology</keyword><keyword>Chronic Disease/epidemiology</keyword><keyword>Confidence Intervals</keyword><keyword>Educational Status</keyword><keyword>Factor Analysis, Statistical</keyword><keyword>Female</keyword><keyword>Health Surveys</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Pain/*epidemiology/etiology/*psychology</keyword><keyword>Prevalence</keyword><keyword>Sex Factors</keyword><keyword>Young Adult</keyword></keywords><urls><related-urls><url> (Print)1203-6765</isbn><custom2>PMC2807773</custom2><titles><title>Factors associated with chronic noncancer pain in the Canadian population</title><secondary-title>Pain Res Manag</secondary-title><alt-title>Pain research &amp; management</alt-title></titles><pages>454-60</pages><number>6</number><contributors><authors><author>Rashiq, S.</author><author>Dick, B. D.</author></authors></contributors><edition>2009/12/17</edition><language>eng</language><added-date format="utc">1528115779</added-date><ref-type name="Journal Article">17</ref-type><auth-address>University of Alberta, Edmonton, Canada. srashiq@ualberta.ca</auth-address><remote-database-provider>NLM</remote-database-provider><rec-number>195253</rec-number><last-updated-date format="utc">1528115779</last-updated-date><accession-num>20011716</accession-num><volume>14</volume></record></Cite></EndNote>189Treatment of patients with COPD and lung cancerAlthough there is currently a lack of clinical evidence, treatment of CKD in patients with COPD appears to be safe.Consensus(95.7%)1st round5Expert opinionThere is no evidence that pharmacological treatment of COPD will cause any changes in patients with CKD and COPD.Consensus(91.3%)1st round--The therapeutic approach to CKD in COPD is no different from patients without COPD, so clinical practice guideline recommendations must be followed.Unanimity1st round5 DAdapted from: ADDIN EN.CITE <EndNote><Cite><Author>Díez-Manglano</Author><Year>2014</Year><RecNum>39592</RecNum><IDText>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</IDText><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>39592</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552094241">39592</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Díez-Manglano, J.</author><author>López-García, F.</author></authors></contributors><titles><title>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</title><secondary-title>Sociedad Espa?ola de Medicina Interna (SEMI) y Elsevier SL</secondary-title></titles><pages>1-259</pages><dates><year>2014</year></dates><isbn>978-84-7592-7626</isbn><urls><related-urls><url><style face="underline" font="default" size="100%"> face="normal" font="default" size="100%">.</style></url></related-urls></urls></record></Cite></EndNote>10 References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbGNhemFyPC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48

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ADDIN EN.CITE.DATA 190,191G) LUNG CANCERConsequences of lung cancer in COPDThe presence of lung cancer should be ruled out in patients with COPD who have symptoms for developing lung cancer.Consensus(95.7%)1st round5 DCompiled by authorsExpert opinionTreatment of patients with COPD and lung cancerThe indication for surgical resectability of lung cancer may be limited by lung function decline in COPD patients.Unanimity1st round4References: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaW08L0F1dGhvcj48WWVhcj4yMDEwPC9ZZWFyPjxSZWNO

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ADDIN EN.CITE.DATA 192COPD patients should receive the treatment recommended in the clinical practice guidelines regardless of whether they have cancer or not.Consensus(91.3%)1st round5 DAdapted from: ADDIN EN.CITE <EndNote><Cite><Author>Díez-Manglano</Author><Year>2014</Year><RecNum>39592</RecNum><IDText>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</IDText><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>39592</rec-number><foreign-keys><key app="EN" db-id="5tzvzvevx50t9sewt07vt9rhrse9fwffdd20" timestamp="1552094241">39592</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Díez-Manglano, J.</author><author>López-García, F.</author></authors></contributors><titles><title>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</title><secondary-title>Sociedad Espa?ola de Medicina Interna (SEMI) y Elsevier SL</secondary-title></titles><pages>1-259</pages><dates><year>2014</year></dates><isbn>978-84-7592-7626</isbn><urls><related-urls><url><style face="underline" font="default" size="100%"> face="normal" font="default" size="100%">.</style></url></related-urls></urls></record></Cite></EndNote>10Supplementary table 6. Recommendations in divergenceRecommendations (R)Final resultsSourceATRIAL FIBRILLATIONR30.The duration of use of high-dose oral corticosteroids should be limited in patients with COPD and atrial fibrillation who are admitted for exacerbations.Divergence(71.4%)2nd roundCompiled by authorsReference PEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gZGVyIEhvb2Z0PC9BdXRob3I+PFllYXI+MjAwNjwv

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ADDIN EN.CITE.DATA 193COGNITIVE DETERIORATIONR51.Patients with COPD and cognitive impairment should be referred for rehabilitation.Divergence(76.2%)2nd roundCompiled by authorReferences: PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5QZXJlaXJhPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48

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ADDIN EN.CITE.DATA 140-142PAINR55.In patients with COPD and pain, nonsteroidal antiinflammatory drugs should be used in preference to opioids.Divergence(61.9%)2nd roundAdapted from ADDIN EN.CITE <EndNote><Cite><Author>Díez-Manglano</Author><Year>2014</Year><IDText>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</IDText><DisplayText><style face="superscript">10</style></DisplayText><record><urls><related-urls><url><style face="underline" font="default" size="100%"> font="default" size="100%">.</style></url></related-urls></urls><isbn>978-84-7592-7626</isbn><titles><title>Protocolos: Manejo Diagnóstico y Terapéutico de las Comorbilidades en la EPOC</title><secondary-title>Sociedad Espa?ola de Medicina Interna (SEMI) y Elsevier SL</secondary-title></titles><pages>1-259</pages><contributors><authors><author>Díez-Manglano, J.</author><author>López-García, F.</author></authors></contributors><added-date format="utc">1512152160</added-date><ref-type name="Journal Article">17</ref-type><dates><year>2014</year></dates><rec-number>153996</rec-number><last-updated-date format="utc">1539176595</last-updated-date></record></Cite></EndNote>10 Reference: ADDIN EN.CITE <EndNote><Cite><Author>Gruber</Author><Year>2003</Year><IDText>Anaesthesia and postoperative analgesia in older patients with chronic obstructive pulmonary disease: special considerations</IDText><DisplayText><style face="superscript">194</style></DisplayText><record><keywords><keyword>Aged</keyword><keyword>*Analgesia, Patient-Controlled</keyword><keyword>Analgesics, Opioid/therapeutic use</keyword><keyword>Anesthesia/*methods</keyword><keyword>Anesthesia, Intravenous/methods</keyword><keyword>Anti-Inflammatory Agents, Non-Steroidal/therapeutic use</keyword><keyword>Humans</keyword><keyword>Nerve Block/methods</keyword><keyword>Pain, Postoperative/*drug therapy/etiology</keyword><keyword>Pulmonary Disease, Chronic Obstructive/*surgery</keyword></keywords><urls><related-urls><url> (Print)1170-229x</isbn><titles><title>Anaesthesia and postoperative analgesia in older patients with chronic obstructive pulmonary disease: special considerations</title><secondary-title>Drugs Aging</secondary-title><alt-title>Drugs &amp; aging</alt-title></titles><pages>347-60</pages><number>5</number><contributors><authors><author>Gruber, E. M.</author><author>Tschernko, E. M.</author></authors></contributors><edition>2003/04/17</edition><language>eng</language><added-date format="utc">1528117578</added-date><ref-type name="Journal Article">17</ref-type><auth-address>Department of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, University of Vienna, Vienna, Austria. eva.gruber@univie.ac.at</auth-address><dates><year>2003</year></dates><remote-database-provider>NLM</remote-database-provider><rec-number>195259</rec-number><last-updated-date format="utc">1528117578</last-updated-date><accession-num>12696995</accession-num><volume>20</volume></record></Cite></EndNote>194 ADDIN EN.REFLIST 1.Barnes P, MacNee W. Fisiopatología celular y molecular de la EPOC. Clinical Publishing; 2001.2.Almagro Mena P. Rodríguez Carballeira M. Afectación extrapulmonar en la EPOC. ?Qué es relevante y cómo debemos evaluarla. 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