COP D: (chronic) Flashcards
COPD Dx
Spirometer: post bronchodilator FEV1/FVC <0.70
COPD presentation
- DYSPNEA - progressive, persistent, and worse with exercise
- Chest tightness post-exerise
- Cough - intermittent or persisent, productive or not
- Chronic sputum production
- Wheezing - varies
- Commorbidites
Risk factors for COPD
- Cigarette smoke
- second hand smoke
- Occupational dust and chimmcals
- Pollution
- Genes: alpha-1 antitrypsin deficiency
- Hx of severe childhood respiratory infections
- Lower socioecoomic status
- Increased age
COPD
preventable and treatale disease that is characterized by persistenatn respiratory symptoms and airflow limitation that is d/t airway and/or alveolar abnormalities usually caused by significant exxposure to noxious particle or gases
- pts have a mix of emphysema and bronchitis
Chronic COPD treatment optiosn
- Bronchodilators
- SABA
- LABA
- SAMA
- LAMA
- Theophylline
- Corticosteroids
- ICS
- systemic
- Phsophodiesterase inhibitors
chronic COPD pharmacotherapy classes
- bronchodilators: short and long acting beta agonsits adn muscarinic antags, theophylline
- inhaled corticosteroids
- phosphodiesterase-4 inhibitor (roflumilast)
Beta agonist MOA in COPD
stimulate beta2 adrenergic receptors → relax airway smooth msucle → bronchodilation
SABA mono prodcuts for COPD
- albuterol MDI, DPI, and neb
- levalbuterol MDI and neb
LABA mono produts for COPD
- salmeterol DPI (also available for asthma)
- formoterol neb
- olodaterol respimat
- aformoterol neb
- indacterol DPI
muscarinic antag MOA in COPD
block bronchoconstrictor effects of ACh on the M3 muscaric receptors in airway smooth msucle
SAMA mono products for COPD
- ipratropium MDI and neb (has a slighly longer duration of action thatn SABAs)
LAMA mono products for COPD
- tiotropium respimat (SMI, also available for asthma) and DPI
- aclidinium DPI
- umeclidinium DPI
- glycopyrrolate DPI and neb
- revefenacin neb
Muscarinic antag ADR
- dry mouth - techincally anticholinergic but little systemic absorption
- Tiotropium may cause metallic taste
theophylline in chornic COPD
not preferred, less effective and less well tolerated than other long acting bronchodilators
Short acting combo products for COPD
SABA + SAMA: albuterol/ipatropium respimat and duoneb
LAMA+LABA combo products for COPD
- Indacaterol/glycopyrrolate DPI (technically LABA/LAMA)
- Tiotropium/oldaterol respimat (SMI)
- Umeclidinium/vilaterol DPI
- Glycopyrrolate/formoterol MDI
- Aclidinium/formoterol DPI
Corticosteroids in chronic COPD
- ICS not as a monotherapy
- NO PO glucocorticods unless exacerbation
ICS/LABA combo products for COPD
- Fluticasone/vilnterol DPI
- Fluticasone/salmeterol DPI and MDI
- Budesonide/formoterol MDI
- Mometasone/formoterol MDI
ICS/LAMA/LABA prodcuts for COPD
not first line
* Fluticasone/umeclidinium/vilanterol DPI
* Budesonide/glycopyrrolate/formoterol MDI
roflumilast MOA in COPD
reduce breakdown of intracellular cAMP → reduce inflamation
- (phosphodiesterase-4 inhibtiors)
Roflumilast ADR
- nausea
- diarrhea
- weight loss
- sleep disturbance
- HA
- worsening of depression
Roflumilast DDI
- CYP 3A4 inhibitors and inducers, 1A2 inducers
- DO NOT USE WITH THEOPHYLLINE
What COPD populations do you NOT use ICS in ever
- Repeated PNA events
- Hx of mycobacterial infection
- Blood eos < 100
Non-pharm COPD
- Smoking cessation
- Vaccine
- Flu
- Pneumoccocal
- TDap
- Zoster (shingles)
- COVID
- Pulm rehab
- Long-term supplemental O2 (goal is >90%)
- Long term is use >15hrs/day
- There are surgical options
COPD assessment
- Confirm dx (FEV1/FVC <0.7)
- Assess airflow obstruction (FEV1 value)
- Assess symptoms and risk of exacerbation
COPD FEV1 assessment
- GOLD 1 - mild: FEV1 >80% predicted
- GOLD 2 - moderate: 50% < FEV1 < 80%
- GOLD 3 - severe: 30% < FEV1 < 50%
- GOLD 4 - very severe: FEV1 < 30%
COPD Group A requirements
- 0 or 1 moderate exacerbations (NOT leading to hospitalzations)
- AND mMRC 0-1 or CAT <10
COPD Group B requirements
- 0 or 1 moderate exacerbations (NOT leading to hospitalzations)
- AND mMRC >2, CAT >10
COPD Group E requirements
- 2+ moderate exacerbations in past year OR
- 1+ in the last year that led to hospitalzation
COPD Group A initial treatment
bronchodilator (LABA or LAMA preferred over SABA or SAMA UNLESS there is only occasional dyspnea)
- still give a SABA, SABA, or SAMA/SABA for symptom relief
COPD Group B intial treatment
LABA+LAMA
- still give a SABA, SABA, or SAMA/SABA for symptom relief
COPD Group E initial treatment
LABA+LAMA (LABA+LAMA+ICS if blood eosinophil >300)
- still give a SABA, SABA, or SAMA/SABA for symptom relief
COPD follow-up: patient has dyspnea as predominant feature
- Escalate to next step (LABA or LAMA → LABA+LAMA)
- Consider switching inhaler type
COPD follow up: patient has exacerbation as predominatn feature
- If on LABA or LAMA,
- Escalate to LABA+LAMA
- If blood eos>300, go all the way to LABA+LAMA+ICS i
- Escalate to LABA+LAMA
- If on LABA+LAMA
- If FORMER smoker, add zithro
- If FEV1 <50% AND chronic bronchitis, add roflumilast
- If blood eos >100, escalate to LABA+LAMA+ICS
COPD ICS descalation
- can consider de-escalating to LABA+LAMA if NO exacerbations in past year
- If pt has a hx of asthma or features of asthma present, ICS is INDICATED
COPD mild exacerbation treatment
SABA
COPD moderate exacerbation treatment
SABA + ABX and/or PO corticosteroids
Asthma-COPD overlap treatment
ICS with LABA+/- LAMA
