COPD guidance & drugs

Question 1

What is step one in treating COPD (hint: PRN drugs)?

Answer 1

SABA or SAMA (Ipratropium) when required

SABA can be continued at all stages but SAMA must be discontinued if a LAMA is used (i.e. wouldn’t be using ipratropium and tiotropium together)

Question 2

If FEV is over 50% what is the treatment plan??

Answer 2

LABA OR LAMA (tiotropium)

If this fails then use LABA + ICS combination inhaler

If this fails triple therapy with all three: LABA + ICS + LAMA

Question 3

If FEV is under 50 % what is the treatment plan?

Answer 3

LAMA alone or LABA/ ICS combination inhaler

(consider LABA/ LAMA combo if ICS declined)

If this fails triple therapy: LABA + ICS + LAMA

Question 4

Name some of the LABA + ICS combination inhalers used in COPD?

Answer 4

LABA + ICS combos are commonly seen in COPD as they are indicated if FEV is over under 50 %
Steroids are only licensed in COPD if given in combination inhalers

Symbicort Turbohaler: Budesonide + Formoterol
Seretide 500 Accuhaler: Fluticasone + Salmeterol

NB: seretide MDI not licensed in COPD

Question 5

If symptoms persist after triple therapy in COPD what should be used?

Answer 5

Theophyllin/ aminophylline

Then Roflumilast

Question 6

What duration of prednisolone is indicated for COPD exacerbations?

Answer 6

30mg daily 7 - 14 days

Can be stopped abruptly as not over 3 weeks use

Question 7

How is oxygen administered in COPD patients?

Answer 7

24-28 % through a venturi facemark to avoid hypercapnia

88-92 % target

Question 8

Why doe patients on nebulisers need to wear goggles with ipratropium nebs?!

Answer 8

Because acute closed angle GLAUCOMA can occur

especially if used with nebulised salbutamol

Question 9

What are the main side effects with anti muscarinic inhalers?

Answer 9

These are ipratropium (SAMA) and tiotropium (LAMA)

Main SE’s:
ARRHYTHMIAS therefore cautioned in CARDIAC DISORDERS. Also need to used with caution with drugs that cause Hypokaleamia/ hyperkaleamia as this can cause arrhythmias

GLAUCOMA- Ipratropium nebs- wear goggles
Antimuscarinic SEs such as dry mouth, constipation, sweating, urinary retention etc but these are more common with oral therapy.

Question 10

What is the risk of INTRAVENOUS SHORT ACTING BETA 2 AGONISTS SUCH AS SALBUTAMOL in DIABETICS?

Answer 10

Risk of HYPERGLYCAEMIA

Also a risk of diabetic Ketoacidosis!!

Question 11

What are the CHM warnings associated with the LABAs formoterol and salmeterol?

Answer 11

Do not prescribe alone- only add on to ICS therapy

Do not initiate in rapidly deteriorating asthma

Don’t used for relief of exercise induced asthma unless regular ICS used too

report symptoms of paradoxical bronchospasm

Question 12

Clear improvement within 3 -4 weeks of ICS therapy indicates which COPD or Asthma?

Answer 12

Asthma

This can be used to differentiate between the two

Question 13

When is Ipratropium not allowed to be continued in COPD?

Answer 13

If patients are on a LAMA (tiotropium)

Question 14

What is spiriva? How often is it given?

Answer 14

Tiotropium

Comes as either Spiriva inhalation powder (18mcg capsules)

or Spiriva Respimat pressurised MDI

It is given OD (One capsule/ 2 puffs of respimat inhaler)

Question 15

What is the role of ICS in COPD?

Answer 15

To reduce exacerbations

Slight lack of evidence of ICS benefits in COPD
Reasonably high doses required (e.g 800mcg budesonide)
Steroids only licensed in COPD if in combination inhalers

Question 16

When should osteoporosis prophylaxis be considered with oral predinisolone use?

Answer 16

received over 3 courses of steroids
lasting over 7 days
in the previous 12 months

All patients over 65 should receive prophylaxis

Question 17

Chronic productive cough in COPD treatment?

Answer 17

Mucolytics:

Carbocisteine/ Mecysteine

Question 18

We know beta blockers are cautioned in asthma… but can they be given in COPD?

Answer 18

Yes… but just monitor closely monitor for broncho spasms

Question 19

What is Aclidinium?

Answer 19

A LAMA also used in maintenance of COPD

Comes as the “Genuair” inhaler- a DPI that has a little window that turns from green to red if dose is inhaled correctly

Question 20

What is Glycopyrronium?

Answer 20

A LAMA used in COPD maintenance

Question 21

What is Umeclidinium?

Answer 21

Another LAMA used in COPD maintenance.

Comes as the Ellipta DPI - has a dose counter- also comes in a combo Ellipta inhaler: Umeclidinium with vilanterol.

Question 22

Tiotropium is a LAMA used for maintenance of COPD but not suitable for treatment of _______

Answer 22

Acute bronchospasm

Question 23

What is paradoxical bronchospasm?

Answer 23

paradoxical means ‘contradictory/ going against oneself’
Paradoxical bronchospasm is where ICS can actually do the opposite to what they’re meant to and cause airways to constrict and breathing to get worse. This means that ICS should not be used again

Question 24

We know salbutamol can cause potassium disturbance… a SABA… Can LABAs?

Answer 24

Yes Laba can also cause Hypokaleamia

Question 25

When does ipratropium bromides maximal effects take place?

Answer 25

30- 60 minutes after use