COPD

Question 1

COPD

Answer 1

Chronic bronchitis + emphysema

Question 2

Rescue therapy options

Answer 2

• SABA
• SAMA
• SABA + SAMA (more effective than either drug alone)

Question 3

SAMAs (-iums)

Answer 3

• Slower onset but longer duration compared to SABA
• Ipratropium
• Ipratropium + albuterol (SAMA + SABA)

Question 4

SAMA MOA and ADR

Answer 4

• ACh released in airways from vagus nerve
• Muscarinic antagonist block ACh to prevent smooth mm contraction and mucus secretion
• ADR: dry mouth most common, caution with glaucoma and BPH

Question 5

Maintenance Therapy

Answer 5

• LABA or LAMA for pts w mod-severe dyspnea OR increase risk of exacerbations
• LAMA > LABA for mod-severe COPD

Question 6

LAMAs (-iums)

Answer 6

• QD agents: *Tiotropium DPI or SMI, Umeclidinium DPI, Revedenacin neb
• BID agents: Aclidinium DPI, glycopyrrolate neb
• 1st line for bronchospasm ass with COPD
• Same interactions and ADRs as SAMA

Question 7

LABAs (-terols)

Answer 7

• QD agents: olodaterol SMI
• BID agents: Salmeterol DPI, Formoterol neb, Afromoterol neb
• Used for bronchospasm ass w COPD

Question 8

LABA/LAMA combos

Answer 8

• Can improve lung fcn and dec sx
• For pts w mod-severe dyspnea, at risk of exacerbation, persistent sx on single long-acting drug
• Glycoprrolate/formoterol HFA BID
• Aclidinium/formoterol DPI BID
• Umeclidinium/vilanterol DPI QD
• Tiotropium/olodaterol SMI QD

-Used these first before ICS/LABA combo

Question 9

ICS/LABA combo

Answer 9

• For pts with mixed asthma/COPD
• ICS monotherapy NOT approved
• Decrease AE-COPD by 25%
• Increase risk of thrush
• Fluticasone/Salmeterol HFA BID
• Fluticasone/Vilanterol DPI QD
• Budesonide/Formoterol HFA BID

Question 10

LAMA/LABA/ICS

Answer 10

• Umeclidinium/vilanterol/fluticasone furoate DPI QD

- Glycopyrrolate/formoterol/budesonide BID

Question 11

Roflumilast

Answer 11

• Tablet for maintenance
• MOA: PDE4 inhibitors –> decreases inflammation
• Indications: severe COPD w chronic bronchitis*
• ADRs: N/V/D most common, CI in liver dz

Question 12

Group A

Answer 12

• CAT score <10, <1 exacerbation, no COPD hospitalizations/yr
• Provide a short or long-acting bronchodilator (albuterol, ipratropium, salmeterol, tiotropium)

Question 13

Group B

Answer 13

• CAT >10, <1 exacerbation, no COPD hospitalizations/yr

- At least 1 long-acting bronchodilator (LAMA > LABA)

Question 14

Group C

Answer 14

• CAT <10, >2 exacerbations or >1 COPD hospitalization/yr
• At least 1 long-acting bronchodilator (LAMA > LABA)
• LABA + LAMA if sx improve c/t using single long-acting bronchodilator
• ICS for more severe cases already on LABA+LAMA or pts with asthma (d/c if improvements seen)

Question 15

Group D

Answer 15

• CAT >10, >2 exacerbations, >1 COPD hospitalizations/yr
• LAMA + LABA
• ICS for same reason as group C

Question 16

Pax Daddy Maintenance

Therapy

Answer 16

• Step 1: SABA +/- SAMA
• Step 2: Add long-acting bronchodilator (LAMA > LABA), if adding LAMA, d/c SAMA
• Step 3: SABA + LAMA + LABA
• Step 4: ICS added for severe dz or those with asthma
• Step 5: add roflumilast

Question 17

Non-pharm maintenance

Answer 17

• Smoking cessation
• O2 therapy–> only therapy shown to alter mortality**
• Immunizations (flu and pneumococcal)
• Pulm rehab

Question 18

AE-COPD tx

Answer 18

• O2 (NIPPV): PaO2 goal 60-70 mmHg, POx 90-94%
• Bronchodilators (all pts): Albuterol +/- ipratropium (MDI or neb)
• Systemic roids (all pts): Methylprednisolone or prednisone
• Abx: when cough and sputum purulence present**

Question 19

Minimizing AE-COPD readmission

Answer 19

• Step 1: written action plan for exacerbations**
• Step 2: rescue q4-6 hr until sx improve
• Step 3: Prednisone x5d
• Step 4: add abx for signs of infection
• Step 5: Prepare for crisis, call 911
• Step 6: Provide close f/u