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PDAT4 > 34/35 - COPD > Flashcards

34/35 - COPD Flashcards

1
Q

Initial Treatment of Stable COPD

What Group & What Drug(s)?

0-1 Moderate Exacerbations
not leading to hospital admin
&
mMRC 0-1 // CAT <10
modified MRC Dyspenea Scale (QOL) // COPD Assessment Test (Symptoms)

A

Group A

ANY BRONCHODIALATOR

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2
Q

Initial Treatment of Stable COPD

What Group & What Drug(s)?

0-1 Moderate Exacerbations
not leading to hospital admin
&
mMRC > 2 // CAT > 10
modified MRC Dyspenea Scale (QOL) // COPD Assessment Test (Symptoms)

A

Group B

LONG ACTING BRONCHODIALATOR

LABA = -TEROLs
Indaca-terol // Oloda-terol // Salme-terol // Formo-terol // Arfomo-terol

LAMA = -IUMs
+Glycopyrrolate // Tiotropium // Aclidinium // Umeclidinium

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3
Q

Initial Treatment of Stable COPD

What Group & What Drug(s)?

> 2 Moderate Exacerbations OR > 1 leading to Hospitilization
&
mMRC 0-1 // CAT <10
modified MRC Dyspenea Scale (QOL) // COPD Assessment Test (Symptoms

A

Group C

  • *LAMA = -IUMs**
  • *+Glycopyrrolate** // Tiotropium // Aclidinium // Umeclidinium
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4
Q

Initial Treatment of Stable COPD

What Group & What Drug(s)?

> 2 Moderate Exacerbations OR > 1 leading to Hospitilization
&
mMRC > 2 // CAT > 10
modified MRC Dyspenea Scale (QOL) // COPD Assessment Test (Symptoms

A

Group D

LAMA or LAMA + LABA or ICS + LABA

  • *LAMA = -IUMs**
  • *+Glycopyrrolate** // Tiotropium // Aclidinium // Umeclidinium
  • *LAMA + LABA**
  • *-IUMs** + -TEROLs
  • *ICS + LABA**
  • *-SONE** + -TEROLs
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5
Q

Acute COPD Exacerbation

TREATMENT

A

Short Burst Corticosteroids

  • *PREDNISONE**
  • *40mg for 5-7 days**

Improves:

  • *spirometry / ABGs / Symptoms**
  • reduced RELAPSE rates @ 30 days*
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6
Q

Risk Factors for COPD

A

Modifiable Risks

  • *TOBACCO Smoke**
  • *Occupational Dust // Air Pollution**

NON-modifiable Risks
ASTHMA
Impaired lung growth // Infections
Genetics - a1-antitrypsin Deficiency

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7
Q

Diagnosis of COPD

A

SPIROMETRY

  • *Symptoms**
  • *Cough / Sputum** (Mucus) / Dyspnea SOB

Exposure to Risk Factors
Tobacco / Occupation / Pollution
A-1 Antitrypsin Levels

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8
Q

Assessment of COPD Exacerbation Risk

“Acute Worsening of respiratory symptoms that result in ADDITIONAL THERAPY”

Mild vs Moderate vs SEVERE

A
  • Blood Eosinophil Count** may also _predict_ *exacerbation rates
  • -> for those patients treated with LABA w/o ICS

Mild = SABD ONLY

Moderate = SABDs + AntiBiotics +/- Oral Corticosteroids

SEVERE = requires HOSPITILIZATION or visits emergency room

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9
Q

Important Health Maintenance for COPD

IMMUNIZATIONS

A

Flu Vaccine –> reduces Serious Illness + Death

ALL SMOKERS SHOULD RECEIVE
–> PNEUMOCOCCAL 23 VACCINE
if 65 y/o+ –> prevnar 13 then 1 year for PCV23
SUBQ or IM
Protects against 85% of INVASIVE Pneumococcal strains

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10
Q

Important Health Maintenance for COPD

PULMONARY REHABILITATION

A

EXERCISE / STRENGTH Training

Education + Adequate Nutrition

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11
Q

Important Health Maintenance for COPD

SMOKING CESSATION

A

MOST EFFECTIVE intervention STOPS & REDUCES progression of COPD

Varenicline
Renal Dosing, CrCL < 30 = 0.5mg QD, MAX 0.5mg BID

Bupropion SR
150mg f3d –> 150mg BID
CI with SEIZURES – Good for Weight Gain + Depression
Hepatic = 150mg QOD // Elderly or Renal = 150mg QD

  • *NRTs**
  • not covered by insurance typically*
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12
Q

Albuterol - Levalbuterol

Type / ADR

A

SABA

Short Acting B2 AGONIST

not completely selective
ADRs:
↑HR & Contraction
HypoKalemia –> leg cramps

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13
Q

Ipratropium

Type / ADRs

A

SAMA
Short-Acting Muscarinic ANTAGONIST

Atrovent HFA MDI
also comes in inhalation solution - 15 min onset of action

ADR:
DRY MOUTH / ↑CV Events
Metallic taste / Blurred Vision
Urinary Retention / Tachycardia

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14
Q

Which LAMA is considered the GOLD STANDARD?

A

LAMA = -IUMs + Glycopyrrolate

TIOTROPIUM
Spiriva Respimat

Glycopyrrolate –> Improved FEV1 > Tiotropium

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15
Q

LAMA
Tiotropium / Aclidinium / Umeclidinium / +Glycopyrolate

USES

Effects on Exacerbations?

A

LAMA

  • *PREVENTS_ & _TREATS**
  • *Exacerbations**

Relieves symptoms / prevents hospitalizations

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16
Q

LAMA
Tiotropium / Aclidinium / Umeclidinium / +Glycopyrolate

ADR / PRECAUTIONS

A

ADR’s are the SAME as SAMA = Ipatropium
Dry mouth / blurred vision / constipation / urinary retention / glaucoma
EXCEPT:
does NOT show increase in CV EVENTS

CI:
Glaucoma / Prostatic HYPERplasia / Renal Impairment CrCl <50 mL/min

17
Q

Combination SABA/SAMA

Advantages

A

Albuterol + Ipratropium = Combivent

Combo provides greater change in spirometry than either agent alone.

Improved adherence & Cost

disadvantage
FIXED DOSE

18
Q

Which LABAs are INHALATION SOLUTIONS?

A

FORMO-TEROL** & **ARFORMO-TEROL

both 1 vial BID

Salmeterol is DPI dosed BID

19
Q

Which LABAs are
ULTRA-LONG-ACTING
“Dosed DAILY”

A
  • *INDACATEROL**
  • *1 CAP for inhalation DAILY,** ArCAPta Neohaler DPI
  • *OLODATEROL**
  • *2 Inhalers DAILY**, Striverdi Respimat

Salmeterol is DPI dosed BID

20
Q

LABA = -TEROLs
Indaca-terol // Oloda-terol // Salme-terol // Formo-terol // Arfomo-terol

USES - Effect on exacerbations?

A
  • *Prevent Exacerbations ONLY**
  • does NOT TREAT* compared to LAMA

Prevent Hospilizations / Relieve Symptoms

21
Q

LABA = -TEROLs
Indaca-terol // Oloda-terol // Salme-terol // Formo-terol // Arfomo-terol

SIDE EFFECTS

A

DPI - DRY COUGH

BLACK BOX WARNING
increased risk of ASTHMA-related deaths
never used ALONE for ASTHMA patients

Insomnia / Tremors / Palpitations

TachyCardia / QT Interval Prolongation / HypoKalemia

22
Q

When would we ADD an ICS for COPD?

A

LABA + ICS

for EXACERBATIONS:
EOS > 300
or EOS > 100 + > 2 moderate exacerbation / 1 hospitilization

Since:
COPD during EXACERBATIONS = EOSINOPHILIC INFLAMMATION

23
Q

Eosinophils & COPD

A

COPD is mainly NEUTROPHILIC Inflammation,
EXCEPT:
During EXACERBATIONS –> EOSINOPHLIC
&
pt with ASTHMA + COPD

Eosiniphils are associated with:
↑Risk of COPD exacerbations
↓Lung Function

24
Q

Which LABA/ICS combination is dosed DAILY?

A
  • *Fluticasone Furoate / Vilanterol**
  • *Breo Ellipta DPI**

1 Inhalation DAILY

25
Q

When would we INITIALLY use

LABA/ICS Combination?

A

ASTHMA + COPD

or

GROUP D + EOS** **> 300
> 2 Moderate Exacerbations OR > 1 leading to Hospitilization
&
mMRC > 2 // CAT > 10

26
Q

When would we use

LABA + LAMA + ICS

Fluticasone furoate/Umeclidinium/Vilanterol
Trelegy Ellipta - QD

A

STEP-UP for:
LABA+LAMA when EOS > 100
or
LABA+ICS and continued Exacerbations

27
Q

ICS - ADRs

ICS is NEVER used ALONE for COPD

Budesonide/ Formoterol

Fluticasone Propionate/ Salmeterol

Fluticasone propionate/ Salmeterol

Fluticasone propionate/ Salmeterol

Fluticasone Furoate/ Vilanterol

A

PNEUMONIA
not DOSE dependent, specific risk factors:
current smokers, prior pneumonia, BMI <25 kg/m2, FEV1≥30%-<50%, poor MRC dyspnea score)

CANDIDIASIS

Dysphonia / Osteoporosis / Cataracts

28
Q

RISK FACTORS

for PNEUMONIA with ICS

A

NOT dose Dependent

Prior exacerbation or Pneumonia

CURRENT Smoker

> 55 y/o

BMI < 25

FEV > 30-50%

Blood Eosinophil < 2%

29
Q

Phosphodiesterase-4 Inhibitors

Drug / Function

A

RFLUMILAST = Daliresp

↑cAMP
in immunomodulatory/inflammatory cells
VV
Relax Airways & supresssion of Smooth muscle mitogenesis
SUPRESSES:
↓NEUTROPHILS / Macrophages / CD8 T-cells

30
Q

When would we use a

PDE4 Inhibitor = Roflumilast

A

STEP UP
for LABA+LAMA but EOS < 100

ADD-ON Therapy
for FEV1 <50% + Chronic Cough/Sputum (bronchitis)
1 hospitilization in past year

NOT USED FOR EMPHYSEMA

250 mcg PO QD f4 weeks –> 500 mcg PQ QD

31
Q

PDE4 INHIBITOR = Roflumilast

ADRs

A

Very common side effects –> Need to TITRATE DOSE
250 mcg QD for 4 weeks –> 500 mcg PO QD

Diarrhea** + **Weight Decrease + Nausea + Depression

Metabolism:
CYP3A4

32
Q

Macrolide Anti-Inflammatory Antibiotics
for COPD

Drugs / MoA

A

Azithromycin** or **Erythromycin

↓Mucus+Sputum Production

  • INHIBIT:*
  • *IL-1 / IL-6 / IL-8 / TNF-a**
  • *oxygen radical production of Neutrophils**
  • Prevent* breakdown of neutrophils –> release TOXIC substances
  • IMPAIR* migration of neutrophils
33
Q

When would we use in COPD

Macrolide Anti-Inflammatory Antibiotics​?

& Limitations

A

Step Up:
FORMER SMOKERS (no longer smoking)
SEVERE COPD + Multiple Exacerbations
Adherence to Bronchodilator & Anti-inflammatory Meds

Limitations:
Hearing Loss / QT interval Prolongation

BACTERIAL RESISTANCE

34
Q

COPD Monitoring

A

Quarterly = CAT (COPD Assessment Test)

Yearly = Lung Function Test

Every Visit:
Smoking Status / Symptoms / Dosing / Adherence
Technique / Exacerbations / Excercise

35
Q

Acute COPD Exacerbations

A

Causes:
UNKNOWN / Viral / Air Pollution / Bacterial

Rule Out:
Pneumonia / CHF / Arrhythmia / Pneomothorax / PE

Symptoms:
↑Breathlessness / Wheezing / Chest Tightness
↑Cough+Sputum
Fever / Change in Color-Tenacity Sputum

36
Q

Home Management of
Acute COPD Exacerbation

A

INTENSIFY Bronchodilator Regimen
Nebulization -> dose more regularly
Albuterol / Ipratropium MDI –> 4-8 puffs
Duoneb –> more doses

ORAL CORTICOSTEROIDS
Prednisone 40mg for 5-7 days

Consider ANTIBIOTICS
3 of the following: ↑Dyspnea / ↑Sputum Volume / ↑Sputum Purulence

37
Q

When to consider ANTIBIOTICS?

for Acute COPD Exacerbation

–Azithromycin or Clarithromycin
–Doxycycline
–Trimethoprim/sulfamethoxazole
–Cefuroxime, cefpodoxime, cefdinir
–Moxifloxacin, levofloxacin
–Amoxicillin-clavulanate

A

requires Mechanical Ventilation
or

3 of the following symptoms:
↑Dyspnea
↑Sputum Volume
↑Sputum PURULENCE

only need 2
if 1 is sputum purulence

38
Q

Long Term Oxygen Therapy
COPD

MoA / Efficacy

A

Main cause of death in COPD
CV disease / Lung Cancer / Respiratory Failure

MoA:
Modest yearly decline in pulmonary artery pressure
REVERSES secondary polycythemia
↑cardiac function test during rest & exercise

Efficacy:
↑Survival / QOL / Exercise tolerance
↑Judgement + Short Term Memory

PDAT4 (34 decks)

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