Chapter 16 Flashcards
Which of the following is an adverse effect of roflumilast that is particularly concerning in
late-stage COPD patients?
A. Hypokalemia
B. Xerostomia
C. Urinary retention
D. Weight loss
Option D: Correct. Weight loss is a common adverse effect from roflumilast therapy. Late-stage
COPD patients are often underweight, so this can be significantly detrimental to their overall
health status.
An 81-year-old woman presents to the emergency department complaining of symptoms consistent with a COPD exacerbation. She has a medical history of COPD, hypertension, heart failure with reduced ejection fraction, and osteoporosis. Her home medications are all dosed appropriately and include albuterol as needed, tiotropium, lisinopril, carvedilol, and spironolactone. After being admitted to the hospital and assuming that all her home medications are continued, which of the following would be the most appropriate medication to add for
treatment of her acute COPD exacerbation?
A. Ipratropium
B. Aminophylline
C. Roflumilast
D. Prednisone
Option D: Correct. The patient should receive a systemic corticosteroid for 5 days during a
COPD exacerbation.
LABAs and/or LAMAs may improve all the following parameters in a COPD patient with an
FEV 1 of 55% predicted except:
A. Symptom frequency
B. Lung function
C. Exacerbation rates
D. Mortality rates
Option D: Correct. Neither LABA nor LAMA therapy has shown a beneficial effect on mortality
rates.
Which of the following medications used for managing COPD works primarily by blocking
muscarinic receptors in bronchial smooth muscle leading to bronchodilation?
A. Indacaterol
B. Fluticasone
C. Umeclidinium
D. Roflumilast
Option C: Correct. Umeclidinium is a LAMA and works via this mechanism of action.
Which of the following may help predict a more favorable response to inhaled corticosteroids
in patients with COPD?
A. Neutrophils
B. Eosinophils
C. Macrophages
D. Lymphocytes
Option B: Correct. Eosinophils are elevated in a subset of patients with COPD and help predict
which patients will respond more favorably to ICS.
- Where in the lungs is the primary site of obstruction in COPD?
A. Large bronchi
B. Large bronchioles
C. Mucus glands
D. Small bronchi and bronchioles
Option D: Correct. Small bronchi and bronchioles are the major site of airflow obstruction due to
fibrosis, increased mucus, and accumulation of inflammatory debris.
A 63-year-old woman presents with cough, minimal sputum production, and dyspnea with
exertion that began over a year ago but has been gradually worsening. She has smoked 1 pack of cigarettes a day for the past 47 years. Which of the following confirms the suspected diagnosis of COPD?
A. PaO 2 60 mm Hg (8.0 kPa) on arterial blood gas
B. Oxygen saturation of 95% (0.95)
C. Postbronchodilator FEV 1 /FVC ratio of 64% (0.64)
D. Postbronchodilator FEV 1 of 75%
Option C: Correct. Postbronchodilator FEV 1 /FVC ratio of less than 70% (0.70) confirms the
diagnosis of COPD.
All of the following are appropriate patient education points for COPD except:
A. Smoking cessation counseling
B. Role of regular exercise
C. Signs and symptoms of an exacerbation
D. When to quit taking medications as symptoms improve
Option D: Correct. Patients should be advised of the importance of medication adherence even
when symptoms are controlled. Adherence helps maintain control and reduces risk of
exacerbations. Once effective medications are started, they are generally continued for the long-
term.
A 59-year-old man with no significant medical history comes to your ambulatory care clinic
for a follow-up visit where he completes pulmonary function tests showing a FEV 1 /FVC ratio of 59% (0.59) and a CAT score of 8. Additionally, he acknowledges that he was admitted to the hospital roughly 2 months ago for a COPD exacerbation. As the clinical pharmacist at the clinic, you are asked what the most appropriate pharmacotherapy would be, assuming that he is on no outpatient medications at this time.
A. Tiotropium daily plus as-needed albuterol
B. Monotherapy with as-needed albuterol
C. Fluticasone/salmeterol twice a day plus tiotropium daily
D. Indacaterol daily
Option A: Correct. A LAMA is indicated due to fewer symptoms (CAT score < 10) and an
elevated exacerbation risk (history of exacerbation requiring hospitalization); this is a group C COPD patient. Additional SABA therapy as-needed is appropriate for intermittent symptoms.
Which one of the following clinical presentations is suggestive of COPD?
A. Sudden onset of cough and large volumes of purulent sputum
B. Chronic cough, sputum production, shortness of breath with activity; symptoms have
gradually worsened over the last year
C. Wheezing and chest tightness that occurs when exposed to strong fumes; symptom onset in
childhood
D. Cough, sputum production, shortness of breath, and fever; symptoms started 1 week ago
Option B: Correct. Chronic cough, sputum production, and dyspnea on exertion are the usual presenting symptoms of COPD.
A 66-year-old man was admitted to the hospital 4 days ago for an acute COPD exacerbation.
During this hospitalization, he has been treated with albuterol 2.5 mg via nebulizer every 4
hours, prednisone 40 mg orally once daily, and azithromycin 500 mg orally once daily, as well as
tiotropium 18 mcg inhaled once daily and theophylline 200 mg orally twice daily. Today he
complains of white patches on his tongue and the inside of his mouth. Which of the following is
the most likely cause of this adverse effect?
A. Prednisone
B. Albuterol
C. Tiotropium
D. Theophylline
Option A: Correct. The patient is complaining of oral thrush, which is a known adverse effect of
prednisone (systemic corticosteroid) use.
A 65-year-old woman with emphysema is seen in clinic today for a checkup. Her current
COPD pharmacotherapy includes tiotropium 18 mcg once daily and albuterol MDI every 4 hours
as needed. She is adherent with medications and uses her inhalers correctly. She reports
increasing albuterol use over the last 3 months due to increased breathlessness; she denies any
recent changes in sputum purulence or volume. Her CAT score today is 23 (compared to 18 3
months ago) and she has not had any exacerbations in the last 3 years. Which of the following is the most appropriate change to her current treatment regimen?
A. Add roflumilast 500 mcg orally every 24 hours
B. Add methylprednisolone 60 mg intravenously every 6 hours
C. Add olodaterol 2.5 mcg two inhalations daily
D. Discontinue tiotropium and start umeclidinium 62.5 mcg one inhalation daily
Option C: Correct. Adding a LABA to LAMA therapy in a patient who has not had frequent
exacerbations but has persistent symptoms is an appropriate stepwise approach to treatment.
A 55-year-old non-smoker presents to the clinic complaining of persistent dyspnea and a
chronic cough over the last 6 months. After appropriate tests are run, he is diagnosed with group B COPD, likely from occupational exposures, and is started on appropriate pharmacotherapy. At this point, which of the following nonpharmacologic recommendations would be most appropriate for this patient?
A. Lung volume reduction
B. Smoking cessation
C. Pulmonary rehabilitation
D. Noninvasive ventilation
Option C: Correct. Pulmonary rehabilitation has been shown to be beneficial for patients with all
stages of COPD. He should be referred to a pulmonary rehabilitation program.
A 67-year-old man with COPD, hypertension, dyslipidemia, coronary artery disease, and
osteoarthritis presents to clinic for routine follow-up. He is currently treated with tiotropium, albuterol as needed, lisinopril, metoprolol, atorvastatin, aspirin, and acetaminophen. He reports no changes in his respiratory symptoms over the last 3 months and his CAT score today is 9. He went to an urgent care facility twice in the past 10 months (last visit 4 months ago) for worsening
COPD symptoms and was started on tiotropium at his last visit. Additionally, he was treated with
antibiotics and prednisone at both urgent care visits. Which of the following is the most
appropriate recommendation to make today?
A. Evaluation of immunization status; administer influenza and/or pneumococcal vaccine if
indicated
B. Add budesonide/formoterol inhaler
C. Add roflumilast
D. Discontinue metoprolol
Option A: Correct. The patient has limited symptoms and had no change in symptoms since the tiotropium was appropriately added to his regimen 3 months ago. However, evaluation of immunization status is warranted, and he should receive the influenza and/or pneumococcal vaccines if indicated.
A 63-year-old man with a medical history of COPD, diabetes mellitus, and GERD presents to
the emergency department complaining of cough, sputum production, and change in sputum color over the last week. He had a similar presentation about 9 months ago and at that time was diagnosed with pneumonia. He reports that his COPD symptoms have been extremely well controlled (CAT scores of 4–6) over the last three years while he has been on as-needed albuterol and umeclidinium, vilanterol, and fluticasone (Trelegy), except for this current episode and during his previous pneumonia diagnosis. A chest x-ray is done and shows a lower lobe opacity in the right lung consistent with pneumonia. His serum eosinophil level is 45 cells/uL (0.045 ×
10 9 /L). Which of the following would be the most appropriate recommendation for managing his COPD?
A. Discontinue the fluticasone
B. Schedule ipratropium/albuterol four times a day in addition to his current regimen
C. Add theophylline to his existing regimen
D. Add morphine for his persistent dyspnea
Option A: Correct. Discontinuing the ICS is most appropriate since his symptoms have been well
controlled outside of two separate diagnoses of pneumonia. Since ICS are known to increase
pneumonia risk (particularly fluticasone) and his serum eosinophil count is < 100 cells/L (0.1 ×
10 9 /L), discontinuation of the ICS is the best option for this patient at this time.
