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Therapeutics > COPD > Flashcards

COPD Flashcards

1
Q

what is the GOLD 2017 definition of COPD?

A

COPD is a common, preventable and treatable disease that is characterized by <b>persistent respiratory symptoms and airflow limitation</b> that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases

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2
Q

what is the hallmark symptom of COPD?

A

dyspnea

-persistent, progressive, worse with exercise/activity

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3
Q

what are symptoms/indicators of COPD?

A

dyspnea, chronic cough (intermittent & unproductive), chronic sputum production

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4
Q

what’s the difference b/w COPD sx’s and asthma symptoms?

A

COPD sx’s are persistent

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5
Q

what is the #1 exposure that leads to COPD?

A

tobacco smoke

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6
Q

why are sx’s persistent with COPD?

A

b/c damage airway and once damage airway, can’t reverse the damage

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7
Q

what is the difference b/w COPD and asthma in terms of airway inflammation?

A

COPD has neutrophilic inflammation (vs asthma as Eosinophilic inflammation)
-neutrophilic inflammation doesn’t respond as well to ICS so beta agnostic or antimuscarinics (bronchodilators) are the staple txt of COPD

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8
Q

what is the staple treatment of COPD?

A

beta agonist or antimuscarinics (bronchodilators)

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9
Q

what do you see on chest x-ray for COPD?

A

hyperinflation

vs asthma is usually normal

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10
Q

what are the COPD phenotypes?

A

Chronic bronchitis & Emphysema

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11
Q

what is Chronic bronchitis?

A

Chronic productive cough for 3 months in each of 2 successive years when other causes of chronic cough have been excluded

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12
Q

what is emphysema?

A

Abnormal permanent enlargement of airspaces distal to the terminal bronchioles

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13
Q

what is asthma-COPD overlap? what meds do you use?

A

3 elements of asthma and 3 elements or more of COPD

Use ICS b/c asthma will respond to ICS

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14
Q

what is the gold standard/required for dx of COPD?

A

spirometry (PFT)

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15
Q

what does underuse of using spirometry to dx COPD lead to?

A

inaccurate COPD dx

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16
Q

what 2 main areas does spirometry measure?

A

he amount of air exhaled (i.e. “volume”) – FVC (forced vital capacity) – total volume able to move out of lungs

The speed in which air is exhaled (i.e. “flow”) – FEV1

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17
Q

what is FEV1?

A

Forced Expiratory Volume in 1 second:

-Volume of air expired in the 1st second of the maneuver

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18
Q

what is FVC?

A

Forced Vital Capacity:

-The total volume of air forcibly exhaled in one breath

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19
Q

what is the FEV1/FVC ratio?

A

The fraction of air exhaled in the 1st second relative to the total volume exhaled

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20
Q

what does the FEV1/FVC tell you?

A

doesn’t say COPD or asthma specifically, but it tells you it’s an obstructive disorder

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21
Q

If FEV1/FVC ratio improves after give SABA, what does that tell you?

A

If improvement of >200ml or 12% increase = asthma

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22
Q

If FEV1/FVC ratio doesn’t improve after give SABA, what does that tell you?

A

that it’s COPD

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23
Q

what is Gold 1?

A

mild COPD

FEV1 ≥80% predicted

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24
Q

what is GOLD 2?

A

moderate COPD

FEV1 ≥50%-80% predicted

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25
Q

what is GOLD 3?

A

severe COPD

FEV1 ≥30%-50% predicted

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26
Q

what is GOLD 4?

A

very severe COPD

FEV1 <30% predicted

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27
Q

what is the health related quality of life & gold spirometric classification questionnaire?

A

Questionnaire that measures quality of life and symptom burden
-The higher the score the worse the symptom burden is

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28
Q

pts with hyperinflation, see increase in what?

A

increase in FRC (functional residual capacity) and IC (inspiratory capacity) goes down

<b>use bronchodilator here</b>
-won’t improve lung fxn but will improve amount of hyperinflation

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29
Q

what does increased FRC and decreased IC mean?

A

hyperinflation

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30
Q

what are the goals of treating COPD?

A

<b>Decrease symptoms</b>

  • relieve symptoms
  • improve exercise tolerance
  • improve health status

<b>Decrease risk</b>

  • prevent progression
  • prevent & treat exacerbations
  • reduce mortality
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31
Q

what is the GOLD definition of EXACERBATION?

A

An acute worsening of respiratory symptoms that <b>results in additional therapy</b>

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32
Q

how do you manage a mild exacerbation?

A

short acting bronchodilator only

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33
Q

how do you manage a moderate exacerbation?

A

short acting bronchodilators PLUS antibiotics and/or oral corticosteroids

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34
Q

how do you manage a severe exacerbation?

A

requires hospitalization or visits the ED, may also be associated with respiratory failure

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35
Q

how do you treat exacerbations?

A

oxygen >90% or PaO2 >60

initiate bronchodilator txt (SABA or combo therapy of beta-2agonists + anticholinergics)

Add oral or IV corticosteroids

Consider abx therapy and provide supportive therapy

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36
Q

if pt is hospitalized for COPD exacerbation and you give them O2, what must you obtain?

A

obtain ABG after 30-60 mins to ensure oxygenation without CO2 retention and/or acidosis

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37
Q

what combo therapy is good for exacerbations?

A

beta2-agonists + anticholinergics

-albuterol + ipratropium (Atrovent)

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38
Q

what does the oral or IV corticosteroids do to help COPD exacerbations?

A
  • Shorten recovery time
  • Improve lung function (FEV1) and hypoxemia (PaO2)
  • Reduce relapse and treatment failure

-Shorter courses of ICS – 5 days for most exacerbations is good for mild to moderate exacerbations

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39
Q

what are the mMRC or CAT scores?

A

indicate symptom burden

Low symptom burden is mMRC 0-1 or CAT <10

High symptom burden is mMRC ≥ 2 or CAT ≥ 10

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40
Q

what is group A for COPD risk groups? what do you use for treatment?

A

Group A = Less symptoms, Low exacerbation risk

  • mMRC 0-1 or CAT < 10
  • 0-1 exacerbations & 0 hospitalizations

Treatment:
Preferred = short or long acting bronchodilator
-evaluate its effects and continue, stop, or try alternative bronchodilator

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41
Q

what is group B for COPD risk groups? what do you use for treatment?

A

Group B = More symptoms, Low exacerbation risk

  • mMRC ≥ 2 or CAT ≥ 10
  • 0-1 exacerbations & 0 hospitalizations

Treatment:
Preferred = LAMA or LABA
-if persistent symptoms, then LAMA+LABA

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42
Q

what is group C for COPD risk groups? what do you use for treatment?

A

Group C = Less Symptoms, High Exacerbation Risk

  • mMRC 0-1 or CAT <10
  • ≥2 exacerbations or ≥1 hospitalizations

Treatment:
Preferred = LAMA
-if further exacerbations… LAMA+LABA (preferred) or LABA+ICS

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43
Q

what is group D for COPD risk groups? what do you use for treatment?

A

Group D = More symptoms, High exacerbation risk

  • mMRC ≥ 2 or CAT ≥ 10
  • ≥2 exacerbations or ≥ hospitalizations

Treatment:
Preferred = LAMA+LABA (can also use LABA+ICS but not preferred)
-persistent symptoms/further exacerbations…LAMA+LABA+ICS
-if further exacerbations: consider Roflumilast if FEV1 <50% & consider macrolide (former smokers)

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44
Q

what is the brand/generic name of short-acting antimuscarinic (SAMA)?

A

ipratropium (Atrovent)

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45
Q

what type of drug is salmeterol?

A

LABA (serevent)

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46
Q

what type of drug is Serevent?

A

LABA

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47
Q

what type of drug is formoterol?

A

LABA

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48
Q

what type of drug is Perforomist?

A

LABA

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49
Q

what type of drug is arformoterol?

A

LABA

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50
Q

what type of drug is Brovana?

A

LABA

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51
Q

what type of drug is indacaterol?

A

LABA

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52
Q

what type of drug is Arcapta?

A

LABA

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53
Q

what type of drug is olodaterol?

A

LABA

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54
Q

what type of drug is Striverdi?

A

LABA

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55
Q

what type of drug is aclidinium?

A

LAMA

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56
Q

what type of drug is Tudorza?

A

LAMA

57
Q

what type of drug is glycopyrrolate?

A

LAMA

58
Q

what type of drug is Seebri?

A

LAMA

59
Q

what type of drug is umeclidinium?

A

LAMA

60
Q

what type of drug is Incruse?

A

LAMA

61
Q

what does regular and pro use of a SABA or SAMA improve?

A

FEV1 and symptoms

62
Q

what do LABAs and LAMAs significantly improve?

A

FEV1, dyspnea, health status, & decrease exacerbation rates

63
Q

combination txt is superior to what?

A

Combination treatment is superior to either class alone at improving FEV1 & symptoms

64
Q

LAMAs have a greater effect on what compared with LABAs?

A

LAMAs have a greater effect on exacerbation reduction compared with LABAs

65
Q

what meds are recommended initial bronchodilators to treat an acute exacerbation?

A

SABA +/- SAMA

66
Q

SAMA may be preferred over what for mono therapy?

A

SAMA may be preferred over SABAs when used as monotherapy in preventing acute mild-moderate exacerbations in patients with moderate-severe COPD

67
Q

what is a SAMA?

A

Ipratropium (Atrovent HFA)

68
Q

what type of drug is Atrovent HFA?

A

SAMA

69
Q

what type of drug is ipratropium?

A

SAMA

70
Q

what is the indication of ipratropium (Atrovent HFA), availability, and features?

A

Indication: Maintenance txt of bronchospasm associated with COPD

Availability:

  • nebulized solution
  • MDI

Features:

  • Dose counter
  • Solution – no shaking required!
  • Priming and cleaning required!
71
Q

what is the short acting bronchodilator combo product? what is the dose? what is the indication?

A 
Combivent Respimat (ipratropium + albuterol)
-SAMA + SABA

Dose: one puff

Indication: COPD uncontrolled on a regular aerosol bronchodilator and require a second

*(DuoNeb = nebulizer formulation)

72
Q

are long-acting formulation bronchodilators preferred over short-acting formulations for COPD?

A

YES!!!

For both beta2-agonists and anticholinergics [antimuscarinics], long-acting formulations are preferred over short-acting formulations

73
Q

when should maintenance therapy with long-acting bronchodilator be initiated for COPD?

A

as soon as possible before hospital discharge

74
Q

when do Respimat products expire?

A

after 90 days

75
Q

what is the onset of Arcapta & Striverdi?

A

5min and last 24 hours

Arcapta = indacaterol
Striverdi = olodaterol
76
Q

what are the long-acting beta agonist for nebulization?

A

Brovana (Arformoterol)

Perforomist (Formoterol Fumarate)

77
Q

what muscarinic receptor do you want to block in the airways?

A

want to block Ach effects at the <b>M3 receptor</b> on airway smooth muscle
-results in bronchodilation

-antimuscarinics block M3 receptor

78
Q

when do all Ellipta devices expire?

A

in 6 weeks

79
Q

what is Anoro Ellipta?

A

LAMA + LABA

80
Q

what is umeclidinium/vilanterol?

A

LAMA + LABA

81
Q

what is Stiolto Respimat?

A

LAMA+LABA

82
Q

what is tiptropium/olodaterol?

A

LAMA+LABA

83
Q

what is Utibron Neohaler?

A

LAMA+LABA

84
Q

what is glycopyrrolate/indacaterol?

A

LAMA+LABA

85
Q

what is Bevespi Aerosphere?

A

LAMA+LABA

86
Q

what is glycopyrrolate/formoterol?

A

LAMA+LABA

87
Q

what is an ICS+LABA more effective at?

A

An ICS + LABA is more effective than the individual components in improving lung function and health status and reducing exacerbations in patients with exacerbations and moderate to very severe COPD

88
Q

regular treatment with ICS increases the risk of what?

A

pneumonia especially intros w/severe disease

89
Q

Triple ICS/LAMA/LABA improved what compared to ICS/LABa or LAMA monotherapy?

A

Triple ICS/LAMA/LABA improved lung function, symptoms, and health status and reduces exacerbations compared to ICS/LABA or LAMA monotherapy

90
Q

if patient is not responding to LAMA/LABA consider what?

A

triple therapy with ICS (ICS/LAMA/LABA)

*Otherwise, unless there is an asthma component, leading towards LABA/LAMA

91
Q

for COPD, what do you not use alone where in asthma you do?

A

For COPD – do not use ICS alone (vs asthma you do)
-ICS becomes the add-on for COPD

SABA is the staple of COPD so give combo of SABA and ICS

92
Q

what is Breo Ellipta? strength approved for COPD? dose? features?

A

ICS/LABA
-only lower strength (100mcg/25mcg) is approved for COPD

Dose: one inhalation/day

Features:

  • no cleaning, no priming, no shaking
  • vilanterol component - bronchodilation approx 5 min
93
Q

what is Trelegy Ellipta? dose? indication?

A

ICS/LABA/LAMA

Dose: one inhalation/day

Indication: Long-term, once-daily, maintenance treatment of patients with COPD, including chronic bronchitis and/or emphysema, <b>who are on a fixed-dose combination of fluticasone furoate and vilanterol</b> for airflow obstruction and reducing exacerbations in whom additional treatment of airflow obstruction is desired <b>or for patients who are already receiving umeclidinium and a fixed-dose combination of fluticasone furoate and vilanterol</b>

94
Q

what is a selective phosphodiesterase 4 (PDE4) inhibitor?

A

Roflumilast (Daliresp)

95
Q

what is Roflumilast (Daliresp)? dose? Pro’s/cons? similar to?

A

PDE4 inhibitor

Once daily <b>“add-on option”</b> in patients not controlled on a bronchodilator (for Group D patients)

Pro’s:
-Oral capsule, Weight loss, May decrease exacerbation frequency

Con’s:

  • Psychiatric disturbances?? – dream disturbances
  • Metabolized mostly via CYP3A4 and CYP1A2
  • Nausea is the most common adverse effect

Similar to theophylline, but has less DDIs and don’t have to monitor levels

96
Q

what is roflumilast?

A

PDE4 inhibitor

97
Q

what is Daliresp?

A

PDE4 inhibitor

98
Q

when do you consider abx therapy for COPD?

A

Consider antibiotic therapy if the patient exhibits:

  • Signs of lower respiratory tract infection
  • Severe exacerbation requiring mechanical ventilation
99
Q

what are the 3 cardinal signs of infection when considering abx therapy for COPD?

A

3 cardinal symptoms of an infection:

  • increased dyspnea
  • increased sputum production
  • increased purulence
100
Q

what sign of infection may you start abx if only 2 cardinal symptoms of infection present?

A

May start antibiotics if only 2 cardinal symptoms are present if one of the symptoms is increased sputum purulence

101
Q

what do you give in combo with abx?

A

oral steroid

102
Q

what course of abx is recommended?

A

shorter course

103
Q

do any of the non-bronchodilator therapies for COPD add benefits?

A

NO!!!

104
Q

what are the non-bronchodilator therapies for COPD?

A
  • mucolytics (e.g. N-acetylcystein, carbocysteine)
  • antitussives
  • Leukotriene modifiers (Zyflo, Singulair, Accolate)
  • Anti-TNF alpha antibody (infliximab)
  • vitamin D
105
Q

what is pulmonary rehab?

A

Multidisciplinary program of care – addresses all the components to help the patient

  • Exercise training
  • Education
  • Psychological counseling
  • Nutritional counseling

Patients at any stage of COPD can benefit – particularly Groups B, C, and D

Usually 6-10 weeks, more than that may not be a benefit

106
Q

what should you follow-up with for COPD patients?

A

Medication adherence and Inhalation technique are most important

107
Q

what vaccine should asthma/COPD patients get?

A

flu & pneumococcal

19-64 y/o give one time dose of PCV23 for asthma & COPD

after 65, give series, start with PCV13, wait a year and give PCV23

108
Q

what is salmeterol?

A

Serevent (LABA)

109
Q

what is serevent?

A

salmeterol (LABA)

110
Q

what is ipratropium?

A

atrovent (SAMA)

111
Q

what is atrovent?

A

ipratropium (SAMA)

112
Q

what is formoterol?

A

perforomist (LABA)

113
Q

what is arformoterol?

A

Brovana (LABA)

114
Q

what is brovana?

A

arformoterol (LABA)

115
Q

what is arcapta?

A

indacaterol (LABA)

116
Q

what is indacaterol?

A

arcapta (LABA)

117
Q

what is striverdi?

A

olodaterol (LABA)

118
Q

what is olodaterol?

A

striverdi (LABA)

119
Q

what aclidinium?

A

Tudorza (LAMA)

120
Q

what is Tudorza?

A

aclidinium (LAMA)

121
Q

what is Seebri?

A

glycopyrrolate (LAMA)

122
Q

what is glycopyrrolate?

A

Seebri (LAMA)

123
Q

what is umeclidinium?

A

Incruse (LAMA)

124
Q

what is Incruse?

A

umeclidinium (LAMA)

125
Q

what is Combivent Respimat?

A

Ipratropium + albuterol (SAMA + SABA)

126
Q

what is DuoNeb?

A

Ipratropium + albuterol (SAMA + SABA) - Neublizer formation

127
Q

what is Ipratropium + albuterol?

A

Combivent Respimat or DuoNeb

SAMA + SABA

128
Q

what is Foradil?

A

formoterol

129
Q

what is formoterol?

A

Foradil

130
Q

what is Anoro ellipta?

A

umeclidinium/vilanterol (LAMA + LABA)

131
Q

what is umeclidinium/vilanterol?

A

Anoro Ellipta (LAMA + LABA)

132
Q

what is Stiolto Respimat?

A

tiotropium/olodaterol (LAMA + LABA)

133
Q

what is tiotropium/olodaterol?

A

Stiolto Respimat (LAMA + LABA)

134
Q

what is Utibron Neohaler?

A

glycopyrrolate/indacaterol (LAMA + LABA)

135
Q

what is glycopyrrolate/indacaterol?

A

Utibron Neohaler (LAMA + LABA)

-dpi

136
Q

what is Bevespi Aerosphere?

A

Glycopyrrolate/formoterol (LAMA + LABA)

it’s a MDI

137
Q

what is Trelegy Ellipta?

A

fluticasone furoate/vilanterol/umeclidinium

ICS/LABA/LAMA

138
Q

what is fluticasone furoate/vilanterol/umeclidinium?

A

Trelegy Ellipta

ICS/LABA/LAMA

Therapeutics (6 decks)

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