COPD Flashcards
what type of inhalers do you shake before use
MDI
SABA/SAMA use in COPD
“rescue” with occasional symptoms or on maintenance therapy
solo SAMA/SABA or SAMA+SABA
SABA+SAMA is more effective than either drug alone
ipratropium
SAMA - usually combined with albuterol for COPD + bronchospasm in the hospital
SAMA ADRs
dry mouth, pharyngeal irritation
best drug to prevent exacerbations in pts with mod-very severe COPD
LAMA > LABA
tiotropium
LAMA (QD)
umeclidinium
LAMA (QD)
revefenacin
LAMA (QD)
aclidinium
LAMA (BID)
glycopyrrolate
LAMA (BID)
list of LAMAs for COPD
tiotropium (QD) umeclidinium (QD) revefenacin (QD) aclidinium (BID) glycopyrrolate (BID) (- ium and -late)
list of LABAs for COPD
indacaterol (QD) olodaterol (QD) salmeterol (BID) formoterol (BID) arformoterol (BID) (-terols)
interactions of B-blockers + LABAs
historically were contraindicated; now are shown to decrease mortality & exacerbations
when would you use dual bronchodilator therapy with LAMA + LABA
moderate-severe dyspnea/symptoms & at risk for exacerbations & for those with persistent symptoms/exacerbations despite use of long-acting bronchodilator
steps of what inhalers you would give COPD patient
SABA –> LAMA –> LAMA+LABA (and still SABA, always)
when would you do an ICS/LABA combo
moderate-severe COPD who experience frequent exacerbations while on > 2 long-acting agents (LABA + LAMA)
or pts with mixed asthma - COPD phenotypes
ADRs of ICS
dysphonia, OP candidiasis, glaucoma, increased risk of thrush, more pneuomonia cases, increased risk of fracture
roflumilast MOA
selective inhibitor of PDE4 = increased intracellular [cAMP] = decreased inflammation
roflumilast indications
severe COPD associated with chronic bronchitis & history of AE-COPD
roflumilast ADRs
N/V/D, weight loss, insomnia, anxiety/depression
theophylline indications
pts with persistent symptoms despite tx with inhaled triple-therapy
GOLD group A treatment
SABA alone
GOLD group B treatment
SABA + LAMA
GOLD group C treatment
ensure on at least long-acting dilator (LAMA>LABA)
2 long acting bronchodilators
reserve ICS for severe disease or pts with asthma
GOLD group D treatment
ensure on 2 long acting meds, reserve ICS
managed by pulmonologist probably
why wouldn’t you want to give a pt a LAMA + ipratropium
both are muscarinic antagonists = more ADRs
use SABA + LAMA instead
steps to managing AE-COPD
- oxygen
- bronchodilators (all pts!) - albuterol +/- ipratropium
- systemic glucocorticoids (all pts!) - prednisone
- abx therapy? - if cough/sputum present
what is the PaO2/POx goal during AE-COPD exacerbation
60-70 mmHg/ 90-94%
how soon after giving O2 should you repeat and ABG
30-60 min
abx for uncomplicated AE-COPD
cephalosporin, doxycycline, Bactrim
abx for complicated AE-COPD
FQ (moxi or levo), amox/clav
abx for AE-COPD if at risk for pseudomonas
levofloxacin, cefepime, ceftazidime, pip/tazo
how often should pts use a reliever inhaler for AE-COPD
q4-6 hr until symptoms improve
dextromethorphan for cough
not effective or safe in young children
DM ADRs
CNS: confusion, excitement, irritability, nervousness
at high doses: N/V, HA
very high: robo-trip euphoria
pharmacologic options for cough
honey DM codeine/hydrocodone benzonatate (tessalong perles) guaifenesin decongestant/ antihistamines SABA/SAMA corticosteroids
benzonatate
alternative to opioids for severe cough
dont use d/t risks
guaifenesin
expectorant
considered safe
not recommended under <12 y.o
how do antihistamines/decongestants work in cough
may reduce PND via antimuscarinic effects
decongestant interactions
should not be used with or within 14 days of a MAOI
phenylephrine drug class
decongestant
decongestant ADRs
increase HR/BP
excitability, insomnia, HA, nervousness, confusion, dizziness
dry nose/throat
SABA/SAMA use in cough
MIGHT benefit, cheap and well-tolerated
for cough that has a bronchospastic component
corticosteroids use in cough
treatment of cough in pts WITHOUT asthma
non-pharm options for cough
saline nasal sprays mist inhalers sialagogues honey menthol or camphor rubs
acute cough 2* to common cold/PND in adults treatment steps
1: antihistamine-decongestant combos
2: naproxen 200-500 mg TID
3: inhaled ipratropium if persisting for 3-8 weeks
4: ICS if ipratropium doesn’t work
5: DM or codeine IF ALL ELSE FAILS + cough persists for 8 weeks
(ANIID)
acute cough 2* to common cold/PND in kids treatment steps
1: saline nasal sprays
2: topical antitussives (vaporub or babyrub if <2 yrs)
3: honey (0.5-2 tsp)
who should not be given honey
infants <1 yr
major complications of smoking
lung cancer, ischemic heart disease, COPD
when do people ususally start smoking
18 y.o (80%)
do men or women have greater risk for dependence and difficulty smoking
women
what is the major neurotransmitter implicated in smoking/tobacco
DOPAMINE
what is the main receptor that mediates nicotine dependence
a4B2
nicotine withdrawl symptoms
“hangriness” - irritability, frustration, anxiety, depressed mood, difficulty concentrating, increased appetite, weight gain, decreased HR, insomnia
5 As of quitting
ASK ADVISE ASSESS ASSIST ARRANGE
short-acting smoking cessation nicotine drugs
gum, inhaler, nasal spray, lozenge
long-acting smoking cessation nicotine drugs
nicotine patch
what to put pts on interested in nicotine replacement products
patch to control sx throughout the day + short-acting form (gum, lozenge)
when to start bupropion
started 7-14 days BEFORE anticipated quit date
varenicline (Chantix)
blocks nicotine (Maureen) from binding (to Alec) & stimulates receptor-mediated activity (Paxton stimulating Alec), but to a lesser degree than nicotine –> stimulation
when to start varenicline
a week BEFORE quit date
who cannot use varenicline
pilots, truckers, bus drivers, air traffic controllers d/t dreams, suicide risk
contraindications to varenicline
pregnancy/breastfeeding
interactions with varenicline
ETOH can cause increased behavior, aggressive behavior, amnesia
varenicline ADRs
dose-dependent nausea
black box warning of neuropsychiatric symptoms & exacerbations of pre-existing psych illness
should we recommend e-cigs for smoking cessation
no or you are dumb
are e-cigs FDA approved for smoking cessation
no
preferred treatment for smoking cessation during pregnancy
counseling
bupropion, varenicline - category C
