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Pharmacotherapy 1 > COPD > Flashcards

COPD Flashcards

1
Q

GOLD guidelines

A

Global Initiative for Chronic Obstructive Lung Disease (GOLD)

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2
Q

GOLD def. of COPD

A

COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and lungs to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.

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3
Q

Risk factors for COPD

A
  1. Smoking
    - up to 25% in US are non-smokers
  2. Environmental Factors
    - occupational dusts & fumes, indoor & outdoor pollution, 2nd hand smoke
  3. Genetics
    - ~1% = inherited alpha-1 antitrypsin deficiency
  4. Other -poor nourishment/socioeconomic status, chronic asthma, repeated lower respiratory tract infections, premature birth
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4
Q

Comorbidities

A

* Cardiovascular disease (most frequent/important)

* Osteoporosis & Depression

* Metabolic Syndrome & Diabetes

* Lung cancer (most common cause of death in mild COPD patients)

* GERD (independent risk factor for exacerbation & associated with worse health status)

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5
Q

Screening & Diagnosis of COPD: COPD should be suspected in any adult over age 40 yrs with…

A

* Classic Symptoms

  • chronic cough, chronic sputum production
  • dyspnea–> progressive, persistent & worse on exertion

* Exposure to risk factors for the disease

-smoking hx (>20pack/years), occupational dusts & chemicals

* Family history of COPD (esp. α-1 antitrypsin def.)

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6
Q

Spirometry

A

should be considered in all patients suspected of (or at risk for) COPD

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7
Q

Spirometry: Parameters Evaluated

A

* FVC (forced vital capacity)

-max volume of gas (L) that can be expired forcefully after a max inspiration

* FEV-1 (forced expired volume in 1 sec)

-volume of gas (L) expired during the first second of a FVC maneuver (performed 15mins after SABA admin)

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8
Q

Spirometry diagnosis and grading

A

* Diagnosis: FEV-1/FVC ratio <0.70 (post SABA)

-confirms presence of persistent airflow limitation

* Grading : % predicted FEV-1 (post SABA)

  • comparison of patients FEV-1 after bronchodilator to what would be expected based on height, age, sex, and race
  • indicates severity of obstruction
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9
Q

Pulmonary Function Tests (PFTs)

A

* Total lung capacity -amount of air in lungs at full inspiration (increased w/ air trapping-emphysema)

* Residual volume -amount of air left after max expiration (increased with air trapping-emphysema)

* Diffusion Capacity (DLCO) -gas-transfer fxn of lungs, CO used as surrogate for O2, reduced value consistent w/ emphysematous changes

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10
Q

GOLD Grading of airflow limitation

A

GOLD 1-mild GOLD 2- moderate GOLD 3- severe GOLD 4- very severe

* see chart

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11
Q

Classification of COPD patients

A

https://s3.amazonaws.com/classconnection/984/flashcards/5918984/png/screen_shot_2015-03-28_at_121437_pm-14C619836CC20476C1D.png

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12
Q

CAT score

A

COPD assessment test (CAT) questionnaire

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13
Q

Goals for Tx of stable COPD

A

* Reduce symptoms

-relieve symptoms, improve exercise tolerance, improve health status (quality of life)

* Reduce risk

-prevent progression, prevent & treat exacerbations, reduce mortality

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14
Q

Non-pharm recommendations for stable COPD

A

* smoking cessation

* vaccinations

* pulmonary rehabilitation

* oxygen

* surgery

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15
Q

Smoking cessation

A
  • 15-25% of smokers develop COPD
  • smoking increases the normal decline in FEV-1
  • smoking cessation can return decline in FEV-1 to normal (that of a non-smoker)
  • smoking cessation = most cost-effective way to reduce risk of developing COPD and stop/slowing its progression, only intervention proven to affect long-term disease progression (decline in FEV-1)
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16
Q

Vaccinations

A

* yearly influenza vaccine

* pneumococcal vaccination (1-time)

 \* 65yrs of age and older

 \* 19-64 yrs of age if chronic lung disease or smoker
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17
Q

Pulmonary Rehabilitation

A

* comprehensive multidisciplinary program (exercise, smoking cessation, nutrition counseling, education)

* Benefits : ↑QOL, recovery from exacerbation, exercise capacity and possibly survival, ↓hospitalizations, depression/anxiety, and breathlessness

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18
Q

Surgery

A

* lung volume reduction surgery (LVRS)→ parts of lungs are resected to reduce hyperinflation

* transplant

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19
Q

Long-term oxygen therapy

A

* patient w/ documented hypoxemia +/- complications of chronic hypoxemia

  • pulmonary HTN or Cor pulmonale= right heart failure -polycythemia= overproduction of erythrocytes (Hct>55%)
  • >15 hours/day is needed (24 hrs=ideal)

* Efficacy : -can improve mortality, symptoms, and reverse long term complications (only helps pts in need of O2)

20
Q

Pharmacologic Options for the Management of Stable COPD

A

* Inhaled bronchodilators (mainstay of therapy

  • B2-agonists: SABAs & LABAs
  • Anticholinergics: SAMAs & LAMAs

* Inhaled Corticosteroids (ICS)

* Phosphodiesterase-4 (PDE-4) Inhibitor

-Roflumilast

* Oral bronchodilators

-Theophylline

21
Q

GOLD Group A Recommended 1st choice

A

SABA prn (or SAMA prn)

22
Q

GOLD Group B Recommended 1st choice

A

LAMA or LABA

23
Q

GOLD Group C Recommended 1st choice

A

ICS+LABA OR LAMA (all pts should also have a SABA prn for acute symptoms)

24
Q

GOLD Group D Recommended 1st choice

A

ICS+LABA+LAMA OR LAMA alone

25
Q

Bronchodilator Therapy Pearls

A

* mainstay of therapy- all improve symptoms (dyspnea & breathlessness) and exercise tolerance

* Not proven to alter the progression of the disease (i.e. long-term rate of decline in FEV1)

* Combining bronchodilators (B2-agonist + anticholinergic) can result in improved efficacy w/ reduced risk for side effects

26
Q

Long-acting bronchodilators

A

* more convenient & effective compared to short-acting bronchodilators

* improve sx, ↓hospitalization, ↓exacerbations and ↑QOL

* 1st choice for Group B patients per guidelines

* No preference on class (B2-agonist vs anticholinergic) per GOLD guidelines

27
Q

LABAs (long-acting B2-agonists)

A
  • Salmeterol: 1 inh q12hrs
  • Formoterol: 1 inh q12 hrs
  • Indacaterol: 1 cap q24 hrs
  • Olodaterol 2 inhs q24 hrs
  • Formoterol: neb q12 hrs
  • Aformoterol: neb q12 hrs ( contraindicated in severe hypersensitivity to milk proteins )
28
Q

SABAs (short-acting B2-agonists)

A

Albuterol: 2 inh q4-6 hrs

Levalbuterol: 2 inh q4-6 hrs

29
Q

LAMAs (long-acting anticholinergic)

A
  • Tiotropium : inh 1 capsule q24 hrs or 2 inh q24 hrs
  • Aclidinium : 1 inh q12 hrs
  • Umeclidinium : 1 inh q24 hrs ( contraindicated in severe hypersensitivity to milk proteins) (use with caution in pts w/ NAG and BPH)
30
Q

SAMA (short-acting anticholinergic)

A

Ipatropium : 2-3 inh q6 hrs (very $$$)

31
Q

Oral bronchodilator: Theophylline

A
  • due to relatively low efficacy & SEs, not recommended unless other bronchodilators are unavailable or unaffordable
  • tablets, capsules, liquid
  • dose-dependent SEs: tremor, tachycardia, insomnia, nervousness, irritability, GI, seizures, cardiac arrhythmias
  • watch out for drug interactions
  • desired serum concentration = 8-12 mg/L
32
Q

Inhaled corticosteroids

A

* ↓exacerbations, improve sx, lung fxn, and QOL (DO NOT alter progression of the disease)

* Add on therapy for pts at high risk for exacerbations or frequent exacerbations (1st choice option in combo w/ LABA for Groups C & D)

* NOT RECOMMENDED AS MONOTHERAPY

* SEs: ↑risk for pneumonia, ↑thrush, bruising, hoarness, risk for worsening sx if D/C

33
Q

Combination ICS + LABA

A
  • * Budesonide/Formoterol –> Symbicort: 2inh q12hrs
  • * Fluticasone/Salmeterol –> Advair Diskus: 1inh q12hrs
  • * Fluticasone/Vilanterol –> Breo Ellipta : 1inh q24hrs
34
Q

PDE-4 inhibitor: Roflumilast

A

↓PDE4⇒↓cAMP metabolism ⇒↑cAMP in lung cells

-FDA indicated to reduce risk of COPD exacerbations in patients w/ severe COPD associated w/ chronic bronchitis and hx of exacerbations -alternative choice for Group C and D

35
Q

Roflumilast

A

500mcg tablet PO once daily

  • $270 30day-supply
  • Contraindicated : mod-severe liver impairment (childs pugh B & C)
  • Warning : worsening insomnia, depression, anxiety, suicidal thoughts
36
Q

Roflumilast

A

* adverse effects: diarrhea, weight loss, nausea, HA, back pain, insomnia, dizziness, psychiatric

* drug interactions: do not use w/ CYP450 inducers, use cautiously w/ CYP3A4 and dual CYP1A2/3A4 inhibitors

37
Q

Daily antibiotic therapy

A

one large study of Azithromycin 250 mg PO daily vs placebo for 1 yr showed significant reduction in time and rate of exacerbations

  • concerns : small increased risk for heaing loss, possible antibiotic resistance, cardiac death from fatal heart arrhythmia
  • Not recommeded in guidelines due to risk>benefit
38
Q

Monitoring response to therapy

A
  • repeat spirometry is NOT reliable
  • options : patient reported sx/activity level, CAT score, 6-minute walk test, QOL questionnaires, other scoring tools
39
Q

Patient education

A

* if still smoking- smoking cessation (mention every time)

* purpose of medications

* expected outcome (benefit) from medications

* side effects

* timing & techniques (MDI/DPI)

40
Q

Acute exacerbation of COPD

A
  • acute event characterized by worsening of the patient’s respiratory symptoms (dyspnea, cough, and/or sputum), beyond normal day-to-day variation and leads to a change in medication
  • precipitating factors : respiratory infection, environmental exposure, (e.g air pollution) non-adherence
41
Q

Consequences of Exacerbations

A
  • negative impact on QOL
  • impact on symptoms and lung function
  • accelerated lung function decline
  • increased mortality
  • increased economic costs
42
Q

Management of Acute exacerbations

A

* Oxygen

-titrate to improve the patient’s hypoxemia w/ target saturation of 88-92%

* Bronchodilators :

  • SABA w/ or w/o SAMA preferred
  • hospitalized/ED patients : admin. by nebulizer easier
  • outpatient mgmt : MDI + Spacer effective
43
Q

Management of acute exacerbations: Antibiotics

A

-consider in hospitalized or ED patients with following cardinal symptoms:

* ↑sputum purulence AND *

↑dyspnea or sputum volume

  • treat for 5-10 days
  • benefits→ ↓tx failure, ↓mortality (ICU pts)
44
Q

Management of acute exacerbations: Systemic Corticosteroids

A
  • recommended in all COPD patients with an exacerbation (short burst)
  • Prednisolone/prednisone 40mg PO daily x 5 days -

Benefits: shorten recovery time, improve lung fxn (FEV1) and arterial hypoxemia (PaO2), and reduce risk of early relapse, tx failure, length of hos. stay

-SEs: hyperglycemia, edema, psych (insomnia, etc)

45
Q

Management of Acute exacerbations: VTE prophylaxis

A

* COPD exacerbation= major risk factor for VTE (venous thromboembolism)

  • prevention of clots in lower extremities for patients the hospital who are immobile or less mobile during hospital stay
  • VTE prophylaxis in COPD exacerbations in hospital
46
Q

COPD Conclusions

A

-3rd leading cause of death -current drug therapies do not alter the progression of COPD or reduce mortality -smoking cessation is the only intervention shown to alter the progression of COPD -1st choice chronic therapy=long acting bronchodilator (LABA or LAMA) -inhaled steroid can be used in combo w/ LABA/LAMA in pt w/ severe disease and hx of exacerbations (C,D)

47
Q

Pharmacists can provide a valuable role in:

A
  • COPD screening
  • smoking cessation
  • pharmacotherapy recommendations
  • healthcare provider education
  • pt education/pt adherence

Pharmacotherapy 1 (4 decks)

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