COPD Pharm Flashcards
SABA side fx
tremor (particularly in the hands, usually disappears as treatment continues), cardiac arrhythmias (more likely in susceptible patients), tachycardia, restlessness, headache, muscle cramps, and nervousness.
- Use cautiously in patients with cardiovascular disorders (e.g., coronary insufficiency, arrhythmias,
hypertension)
SAMA side fx
headache, throat irritation, cough, dry mouth, GI motility disorders, dizziness, bitter/metallic taste. Use cautiously and monitor for worsening urinary
retention in patients with preexisting urinary tract obstruction.
• Use cautiously in patients with narrow angle glaucoma.
SAMA an LAMA should not be used concurrently
Strong support for initiating ICS with these factors (4)
- history of hospitalization(s) for AECOPD
- > 2 moderate AECOPD per yr
- blood eosinophils >300 cells/uL
- hx of or concomitant asthma
Consider use of ICS (2)
- 1 mod AECOPD per year
- blood eosinophils 100-300
Against Use of ICS (3)
-repeated pneumonia event
-blood eosinophils <100
-history of mycobacterial
infection
ICS benefits?
For persistent exacerbations or breathlessness , not for mono-therapy
- Use lowest effective dose
- Regular treatment improves symptoms, lung function and QoL, reduces frequency of
exacerbations in patients with FEV1<60% predicted
ICS side fx
Oropharyngeal candidiasis (thrush), dysphonia, sore mouth, sore throat
● Systemic SE of long term treatment with high dose ICS
Step therapy
Group A (MMRC 0-1, CAT<10, 0-1 exac)
what is initial therapy?
next step?
- A SABD (prn) or LABD
- Continue if symptomatic benefit documented D
Step therapy
Group B (MMRC >/= 2, CAT >/= 10, 0-1 exac)
what is initial therapy?
next step?
LABA or LAMA (no evidence for one class over another)
- If persistent symptoms on mono therapy then LABA +LAMA
- If no response on combostep back to 1 & assess comorbidities
Step therapy
Group C (MMRC 0-1, CAT< 10, >= 2 or >= 1 leading to hospital admin exac)
what is initial therapy?
next step?
LAMA (superior to LABA in this grp)
- If persistent exacerbations step up to LABA+LAMA
- LABA/ICS if asthma/COPD overlap
Step therapy
Group D (MMRC >=2, CAT >/= 10, >= 2 or >= 1 leading to hospital admin exac)
what is initial therapy?
next step?
LAMA or LABA+LAMA or ICS + LABA*
* Consider if eosinophil count 300
- if persistent exacerbations step up to LABA+ICS+LAMA
- if on LABA/ICS step up to LABA+ICS+LAMA
Oral corticosteroids: Prednisone
see side fx
- Long term treatment with oral corticosteroids should not be used in COPD
- absence of benefit in most patients and the high risk of adverse systemic effects
short-term AECOPD
Phosphodiesterase inhibitors: Roflumilast (Daxas®)
Non-steroid anti-inflammatory; Role not entirely clear
- Add-on therapy to bronchodilator treatment
o maintenance treatment of severe COPD associated with chronic bronchitis
o History frequent AECOPD
Oral/iv methylxanthines
Theophylline oral/aminophylline intravenous
Place in therapy: Not first or second line, but considered as “another possible treatment” for managing stable COPD.
▪ Side effects: nausea, vomiting, abdominal cramps, headaches, nervousness, tremor, insomnia, tachycardia, tachypnea, seizures, coma, respiratory depression
define AECOPD = lung attack
causes?
An acute event characterized by a worsening of symptoms (dyspnea, cough, sputum production) that is beyond normal day to day variation, is acute in onset, and leads to a change in regular medications
causes ● Infection ● Air pollution ● 1/3 no cause ● Other: pleural effusion, heart failure, pulmonary embolism, pneumothorax
Consequences of AECOPD
see signs and symptoms
● Increased mortality ● Negative impact on QoL ● Accelerated lung function decline ● Impact on symptoms and lung function ● Increased economic costs
AECOPD Classification
3 cardinal symptoms
Cardinal symptoms include:
● worsening of dyspnea,
● increase in sputum volume
● increase in sputum purulence
AECOPD Classification
mild?
how to treat?
1 cardinal symptom plus at least 1 of the following URTI within 5 days
- fever without other explanation
- increased wheezing
- increased cough
- increase in respiratory or heart rate >20% above baseline:
Treated with SABD only
AECOPD Classification
moderate?
how to treat?
2 cardinal symptoms
Treated with steroids +/- ABX
AECOPD Classification
severe?
how to treat?
3 cardinal symptoms
ER or hospitalized
AECOPD non-pharm
Oxygen: titrate to improve hypoxemia with target O2 saturation of 88-92%
● Non-invasive mechanical ventilation – consider for acute respiratory failure
AECOPD Pharmacologic Treatment
3 things
SABD preferred, SABA may be added if symptoms perisist
Systemic corticosteroids shorten recovery time, improve lung function and arterial hypoxemia, reduce risk of early relapse
o Prednisone 40 mg daily x 5 days
Antibiotics o Should be given to patients with ▪ 2 cardinal symptoms: increased dyspnea, increased sputum volume and increased sputum purulence (Dipiro) ▪ Requiring mechanical ventilation
what antibiotics should be used in this situation:
< 4 exacerbations per year And at least 2 of the following: - Increased sputum purulence - Increased sputum volume - Increased dyspnea
amoxicillin
doxycycline
trimethoprim/sulfamethoxazole
Treat for 5-7 days
Evidence indicates 5 days may be as effective as 7-10 days
what antibiotics should be used in this situation:
>4 exacerbations per year and at least 2 of the following: - Increased sputum purulence - Increased sputum volume - Increased dyspnea Or - Failure of first line agents Or - Antibiotics in past 3 months
Amoxicillin- clavulanate
Cefuroxime
Levofloxacin
alternatives: azithromycin, clarithromycin
- Failure of first line agents: improvement following completion of ABX therapy OR clinical deterioration after 72 hrs of ABX therapy
- Use a different class than was used previously
- Due to the broad spectrum of levofloxacin, potential for increasing resistance and risk of C.difficile infection, reserve this mediation for beta-lactam allergies or failure to first line agents
- macrolides poor Haemophilus coverage and significant S. pneumoniae resistance (more anti-inflamm properties)
