COPD- Management therapy

Question 1

FYI

note this is not a stepwise approach but an expanding menu of options

Answer 1

fyi

Question 2

What should accompany all therapies across the spectrum of COPD

Answer 2

SABD

Short acting bronchodilators

This is a broad term that encompasses SABAs and SAMAs

Pts have on hand- used in AECOPD

Question 3

What are SABAs

Answer 3

short acting beta agonists
stimulate beta 2 receptors causing smooth muscle relaxation and bronchodilation

Salbutamol (Ventolin/Albuterol)
Terbutaline (Bricanyl)

Question 4

What are SAMAs

Answer 4

short acting muscarinic antagonists
block muscarinic receptors preventing acetylcholine from causing bronchoconstriction :. causing bronchodilation

Ipratropium bromide (Atrovent)
can have combo SAMA+SABA like combivent

Question 5

What things go into considering a patients symptom burden

3

Answer 5

SOB
activity limitation
impaired health status

Question 6

What puts a COPD patient at “low risk” of AECOPD

AECOPD- acute exacerbation COPD

Answer 6

1 or less moderate (requiring ABX or pred) exacerbation in the last year

Question 7

What puts a COPD patient at “high risk” of AECOPD

Answer 7

2 + moderate exacerbations (needed ABX +/- steroids) in last year
or
1+ severe exacerbations (ED or hospitalization in last year)

Question 8

What is the mMRC score

Answer 8

the modified medical research council dyspnea scale–> tool used to assess severity of breathlessness (dyspnea) in COPD patients

Question 9

What is the CAT score?

Answer 9

COPD assessment tool
used to assess symptom burden and QOL
<10 = low impact
10+ = mid-high impact

Question 10

For stable COPD patients with:

• low risk of exacerbations
• low symptom burden and health status impairment (CAT<10, mMRC 1)
• mildly impaired lung function (FEV1 80+)

What is first line monotherapy for COPD?

Answer 10

LAMA OR LABA

LABA- long acting beta agonist

both long acting bronchodilator (LABD)

LAMA- long acting muscarinic antagonist
recall LAMAs are anticholinergics

note LABD is a broad term that encompasses LAMAs and LABAs

Question 11

For stable COPD patients with:

• low risk exacerbations
• mod-high symptom burden and health status impairment (CAT10+, mMRC 2+)
• impaired lung funtcion (FEV1 <80)

What should be started for** initial maitenance therapy?**

Answer 11

LAMA+LABA
dual therapy

LABA- long acting beta agonist

LAMA- long acting muscarinic antagonist
LAMAs are anticholinergics

Question 12

When is the only time just an ICS+LABA should be used

Answer 12

pt with concomitant asthma

Question 13

For stable COPD patients with:

• low risk exacerbations
• mod-high symptom burden and health status impairment (CAT10+, mMRC 2+)
• impaired lung funtcion (FEV1 <80)

Inital therapy should be dual LAMA+LABA therapy (or LABA+ICS if asthmatic).

What is the step up if that doesnt work?

Answer 13

LAMA+LABA+ICS

Add ICS
Triple therapy

Question 14

What is the best option to alleviate dyspnea and other symptoms as well as improve heath status?

Answer 14

combine pharmacotherapy with pulmonary rehab

Question 15

What do LAMAs do

LAMA- long acting muscarinic antagonist
LAMAs are anticholinergics

Answer 15

block muscarinic receptior in bronchial smooth muscle- prevents acetylcholine from binding :. relaxation of bronchial smooth muscle

Question 16

What are examples of LAMAs

recall LAMAs are anticholinergics

Answer 16

Tiotropium (Spiriva)
Umeclidinium (Incruse Ellipta)

Question 17

Most common side effect of LAMAs

Answer 17

dry mouth from anticholinergic action

inhibits glandular secretion at muscarinic receptors

Question 18

What treatment should not be used as monotherapy for COPD

Answer 18

ICS

Question 19

For stable COPD patients with:

• moderate to high symptoms and
• impaired lunch function (FEV1<80)
• high risk of exacerbation

what is first line initial maintenance therapy

Answer 19

LAMA
+
LABA
+
ICS

preference for single inhaler triple therapy (SITT) >3 seperate inhalers

Question 20

For stable COPD patients with:

• moderate to high symptoms and
• impaired lunch function (FEV1<80)
• high risk of exacerbation

These patients should be on triple therapy (ICS+LABA+LAMA)

If still having exacerbations what is add on therapy

Answer 20

add on macrolide maitenance therapy

caution hearing impairment, cardiac arryhthmia (QT prolongation), microbial resistance

Question 21

What are the 2 most common macrolides used in AECOPD prone patients to reduce risk of exacerbation

Answer 21

azithromycin or erythromycin

Question 22

What is a moderate AECOPD

acute exacerbation COPD

Answer 22

exacerbations requiring ABX +/- pred treatment

Question 23

What is a severe AECOPD

Answer 23

require ER or hospitalization

Question 24

fyl

Question 25

When are PDE4 inhibitors used in COPD

Answer 25

Pts with chronic bronchitis and severe-very severe COPD + history exacerbations

improves lung function and reduces exacerbations

most common choice is Roflumilast

Question 26

fyl