COPD

Question 0

Anti-cholinergics

Answer 0

MOA: block the action of acetylcholine at parasympathetic sites and bronchial smooth muscle causing bronchodilation

Short acting agents: Ipratropium bromide (art overt HFA), ipratropium plus albuterol (Combivent respimat, Duoneb)

Long-acting agents: Tiotropium (Spiriva), aclidinium (tudorza)

Warning: use with caution in patients with myasthenia gravis, narrow angle glaucoma, urinary retention, BPH or bladder neck obstruction

Side effects: dry mouth, URTI, nasopharyngitis, sinusitis, cough and bitter taste

Notes: avoid spraying in the eyes, do not swallow capsules of Tiotropium

Question 1

Degree of airflow limitation

Answer 1

Gold one (mild): FEV1>\=80% predicted
Gold two (moderate): between 50% and 80%
Gold three (severe): between 30% and 50 
Gold four (very severe): < 30%

Question 2

Long acting beta agonist

Answer 2

1. Salmeterol (Serevent)
2. Salmeterol plus fluticasone (Advair)
3. Formoterol (foradil)
4. Formoterol plus budesonide (Symbicort)
5. Vilanterol/fluticasone (Breo Ellipta)

Blackbox warning: increased risk of asthma related deaths
Side effects: tachycardia, tremor, shakiness, lightheadedness, cough, palpitations, hypokalemia and hyperglycemia

Notes: bronchodilator combination with steroids can increase the risk of pneumonia has also shown to decrease the number of exacerbations; rinse mouth with water and spit for all steroid containing inhalers

Question 3

Phosphodiesterase four inhibitor

Answer 3

MOA: Reduced lung inflammation

Does not cause bronchodilation and should never be used monotherapy

Drug: roflumilast (daliresp)

Contraindication: moderate to severe liver impairment

Side effects: diarrhea, weight loss, nausea, decreased appetite, insomnia, depression and psychiatric events including suicidality

Monitoring: signs and symptoms, LFTs, smoking status, COPD questionnaire, spirometry yearly

Should only be used in severe COPD and which other options have failed

Question 4

Combivent Respimat inhaler counseling

Answer 4

1. May increase eye pressure which may cause or worsen some types of glaucoma
2. May cause difficulty with urination
3. Stop taking and call the doctor right away if the first two occur
4. Can cause dizziness and blurred vision used caution when driving
5. Do not use more often than directed as it is very dangerous
6. Tell your doctor if you have glaucoma, prostate or urinary problems, a history of heart conditions or high blood pressure, seizures, thyroid disorder, diabetes, low potassium or kidney or liver disease
7. Most common side effects include infection of the ears, nose and throat, runny nose and cough, bronchitis, headache and shortness of breath