COPD therapeutics Flashcards
What does the mMRC questionnaire ask for?
Description of breathlessness after exercise or normal activity
- Dyspnea
What factors are in the COPD assessment test (CAT)?
Both respiratory symptoms and functioning
Define group A COPD characteristics
Exacerbations?
mMRC score
CAT score
Exacerbations?
- 0 or 1 NOT LEADING TO HOSPITAL
mMRC score: 0-1
CAT score: under 10
Define group B COPD characteristics
Exacerbations?
mMRC score
CAT score
Exacerbations?
- 0 or 1 NOT LEADING TO HOSPITAL
mMRC score: 2+
CAT score: 10+
Define group E COPD characteristics
Exacerbations?
mMRC score
CAT score
Exacerbations?
- 2+ Moderate exacerbations
- 1+ LEADING TO HOSPITAL
mMRC score: 2+
CAT score: 10+
What is the BODE index used for? What are the factors?
To predict mortality
B= BMI
O = obstruction (FEV1)
D = Dyspnea (mMRC)
E = exercise capacity (distance walked in 6 min)
What do COPD exacerbations look like (3 main symptoms)
Acute changes in:
1. Cough increases in frequency + severity
2. Sputum production inc in volume / character
3. Dyspnea increases
What are the therapeutic strategies level in COPD (5)
- Smoking cessation , healthy lifestyle, SABA PRN
- Inhaled maintenance/preventative pharmacotherapies
- Pulmonary rehab
- Other pharmacotherapies
- Oxygen +/- NIV (non-invasive ventilation)
- Surgical/endoscopic therapy
When is pulmonary rehab recommended? what group of patients?
Prevents hospitalization if initiated less than 4 weeks after an exacerbation
- encouraged for Group B and E patients
SABA (2)
MOA
PD (side effects) (4)
Onset
Duration
SABA (2)
1. Salbutamol
2. Terbutaline
PD
- tachycahardia
- tremor
- hypertension
- difficulty sleeping (common)
MOA
- relaxes bronchial smooth muscle
Onset: 1-3 min
Duration: 4-6 hours
SAMA (1)
MOA
PD (side effects) (3)
Onset
Duration
SAMA (1)
1. Ipratropium
PD
- Headache
- Dry mouth
- UTI
MOA
- Blocks ACh in bronchial smooth muscle
- decrease PSNS activity in lungs
- bronchodilation
Onset: 15 min
Duration: up to 8 hours
Is SAMA/SABA combo better than SAMA and SABA alone? What combination exists (1)
Combo more effective than single therapy
- attacking smooth muscle in 2 different ways
- Ipratropium + salbutamol
Can ICS be used alone in COPD?
Never
ICS (5)
MOA
PD (side effects) (3)
Onset
Duration (for clinical benefit)
ICS (5)
1. Ciclesonide
2. Mometasone
3. Fluticasone furoate (COPD, more potent) propionate (Asthma)
4. Budesonide
5. Beclomethasone
MOA
- Anti-inflammatory
- Immunosuppressive
- Anti-proliferative
PD (side effects) (3)
- Oral candidiasis
- UTRIs
- Hoarse voice
Onset: 24 hours
Duration: 2-4 weeks for clinical benefit
LABA (4)
Onset
Duration
LABA (4)
1. Formoterol
2. Indacaterol
3. Salmeterol
4. Olodaterol
Onset
1-3 min: Formeterol, indacaterol, olodaterol
30-50 min: Salmeterol
Duration
12 hours: formterol, Salmeterol
24 hours: Indacaterol, olodaterol
LAMA (4)
MOA
Onset
Duration
LAMA (4)
1. Tiotropium
2. Glycopyrronium
3. Umeclidinium
4. Aclidinium
MOA
- competitively and reversible inhibition of ACH action at M3 receptors
- causes bronchodilation
Onset
- 15 min: glyco, ulme, aclidi
- 30 min: tio
Duration
- 12 hours: aclid
- 24 hours: Tio, glyco, ulme
**take weeks to get a clinical benefit
What are the LABA/ICS combo available for COPD? (3)
Which is the only combo with duration of 24 hours?
- Fluticasone prop/salmeterol ADVAIR diskus
- generic: WIXELLA - Budesonide/formoterol SYMBICORT
- fluticasone furoate/ vilanterol BREO ELIPTA
24 hour duration
- fluticasone furoate / vilanterol
What are the LAMA/LABA combos available (4)
- ume/vilanterol
- Aclidi/ formoterol
- Tio/olodaterol
- glyco/indacterol
What are these groups usually prescribed as initial treatment
Group A
Group B
Group E
Group A
- bronchodilator (LAMA is best)
Group B
- LABA/LAMA combo
Group E
- LABA/LAMA combo
- if eosinophils 300+ consider LABA/LAMA/ICS
What is the general rule based on patient’s current long-acting inhaler therapy? (2)
- Patient can always use a SABA
- If a patient on a LAMA –> dont use a SAMA
What do you give if a patient is neither on a LABA or LAMA
can give a SABA and/or SAMA
Is SABA/SAMA combo more effective for DYSPNEA for reliever than monotherapy
Yes, due to different
- sites of action
- mechanisms of action
- onset/durations of action
Group A patients:
1. if they are experiencing only occasional breathlessness (dyspnea) what do you give?
2. What if initial treatment not working?
3. What if frequent use of treatment?
- Short acting bronchodilator (SABA)
- Take duo therapy SABA/SAMA
- Choose a LABA or LAMA
Which is better for reducing dyspnea, exacerbations, FEV1, use of salbutamol: LABA or LAMA
LAMA
Is LABA effective as monotherapy. What was the outcome?
Yes
- decreased exacerbation
- decrease use in SABA
- improved FEV1
Can group A patients that have CV problems/complications start LAMA
Yes
In group B patients
1. is LABA/LAMA more effective than LABA
2. Is LABA/LAMA more effective than LAMA
- Yes
- No significance
Can you use LABA + ICS in group E COPD patients
never
- has more side effects than LABA/LAMA
What is the best treatment for Group E patients? When should you avoid ICS (3)?
LABA/LAMA/ICS
Against use of ICS:
- repeated pneumonia events
- eosinophils UNDER 100
- History of mycobacterial infection
What was the outcome when using LABA/LAMA/ICS against LABA/LAMA? (1)
Triple therapy with high dose ICS reduced ALL-CAUSE MORTALITY compared to duo therapy
Can you give triple therapy for patients with eosinophils below <150? Is it more effective than duo therapy?
Yes.
- same efficacy as duo therapy in eos <150
When is ICS/LABA given? What if their symptoms or exacerbations get worse?
If patient has concomitant asthma
- if symptoms or exacerbations get worse, increase ICS/LABA dose or add LAMA
What should you do if a COPD patient is on an ICS/LABA WITHOUT asthma
- taper down ICS dose
- switch to LABA/LAMA
Which more effective at reducing exacerbations in GROUP E/mod-very severe patients: ICS/LABA or LABA
ICS/LABA
Steroid use in COPD
Long-term NOT recommended (oral or inhaled)
- can use short-term
If a patient is suffering from Dyspnea at FOLLOW-UP (not the first ABE treatment) what is the algorithm of treatment (3)
- LABA or LAMA
- LABA/LAMA combo
- Switch LABA/LAMA combinations
If a patient is suffering from Exacerbations at FOLLOW-UP (not the initial ABE treatment) what is the algorithm of treatment if on a LABA or LAMA?
- LABA or LAMA
- LABA/LAMA if eos <300
- LABA/LAMA/ICS if eos 300+
If a patient is suffering from Exacerbations at FOLLOW-UP (not the initial ABE treatment) what is the algorithm of treatment if on a LABA/LAMA combo + eos <100 or 100+?
LABA/LAMA + eos <100
1. Go to roflumilast (FEV1 < 50% & has chronic bronchitis) OR
1. Azithromycin (former smoker)
LABA/LAMA + eos 100+
1. LABA/LAMA/ICS
If a patient is suffering from Exacerbations at FOLLOW-UP (not the initial ABE treatment) what is the algorithm of treatment if on a LABA/LAMA/ICS?
- Go to roflumilast (FEV1 < 50% & has chronic bronchitis) OR
- Azithromycin (former smoker)
If a patient is suffering from Exacerbations at FOLLOW-UP (not the initial ABE treatment) what is the algorithm of treatment if on a LABA/LAMA/ICS + eos 300+?
Taper OFF ICS dose (12 weeks)
- go back to LABA/LAMA
What was the outcome of ICS tapering (12 weeks) vs ICS continuing
Tapering did not increase risk of exacerbation
- only resulted in a small drop of FEV1 and patient functionality
Non-inhaled therapy: Roflumilast
Class
MOA
is it a bronchodilator?
Can give as single therapy?
Contraindication?
Efficacy?
Class: Selective PDE-4 inhibitor
MOA
- has some anti-inflammatory action
is it a bronchodilator?
- not a direct bronchodilator
Can give as single therapy?
- no give with LABA
Contraindication
- If a patient is losing a lot of weight
- Depression
Efficacy
- improves lung function and reduces exacerbation risk
- Does NOT reduce mortality or improve QoL
Azithromycin outcome
Efficacy
Safety
Good for patients who have a smoking history of at least 10 pack-years
Efficacy
- increased time to first exacerbation
- decreased frequency of acute exacerbation
Safety
- higher rates of hearing loss
What vaccines are recommended in COPD patients
- Flu
- COVID
- Pneumococcal (PCV-20 preferred)
- TdaP (tetanus, diphtheria, pertussis) (due to whooping cough)
- Shingles (50+) (can get chicken pox in abdomen)
What is Alpha-1-Antitrypsin augmentation indicated for?
Young patients with genetic deficiency of emphysema (stiff alveoli)
What is vitamin D indicated for in COPD patients?
reduces exacerbations in patients with low baseline levels
What are opioids indicated for in COPD patients?
In severe dyspnea when they are in palliative care
- causes respiratory drive –> makes them more comfortable instead of gasping for air all the time
What type of inhalers use SLOW laminar inspiration and propellant?
What type of inhalers use Fast deep strong breath with no propellent?
Slow laminar (aersols) w/ propellant
- MDI
- Respimat
Fast deep strong breath with no propellent
- the rest
Nebulizer efficacy w salbutamol
- Early benefit at 5 min
- No difference at 45 min
If you have poor dexterity/coordination, which drug delivery method would you
Prefer?
Avoid?
Prefer
- DPI
Avoid
- Dry powder capsules
- Aerosols (MDI, respimat)
If you have poor inspiratory force, which drug delivery method would you
Prefer?
Avoid?
Prefer (aerosols)
- MDI + nebulizer
- Respimat
Avoid
- DPI
- Dry powder capsule
If you have many puffer types, which drug delivery method would you
Prefer?
Avoid?
Prefer
- turbohalar
- MDI
- Diskus
Avoid
- MDI
- Dry powder capsule
- ellipta
- respimat
How do you choose an inhaler delivery device within a class?
Solely based on MD & patient preference
What bacteria grew in sputum sample of COPD (3)
Which are most common
- H. flu (most common grew)
- Pseudo aeruginosa (more likely in severe patients)
- Strep. pneumo
What is the strongest predictor of having a future exacerbation
Having a history of exacerbations
What are the most common causes of COPD exacerbations? (2)
- having a respiratory tract infection
- air pollution
Define exacerbation
- increased dyspnea and/or cough + sputum that worsens in less than 14 days
- can have tachypnea and/or tachycardia
Define mild exacerbations
Dyspnea VAS
RR
HR
Resting SaO2
CRP
Dyspnea VAS < 5
RR: < 24 breaths/min
HR: <95 bpm
Resting SaO2: 92%+ and change <3
CRP: <10mg/L
Define moderate exacerbations
Meet how many criteria
Dyspnea VAS
RR
HR
Resting SaO2
CRP
Meets 3/5 criteria
Dyspnea VAS: 5+
RR: 24+breaths/min
HR: 95+
Resting SaO2: <92% and change 3%+
CRP: 10+mg/L
Define severe exacerbations
Dyspnea VAS
RR
HR
Resting SaO2
CRP
Same as moderate
ABG show worsening hypercapnia and acidosis (PaCO2 > 45 mmHg and pH <7.35)
What are indicators for hospitalization for exacerbations in COPD
- severe symptoms (above)
- acute respiratory failure
- onset of new symptoms (cyanosis, peripheral edema)
- Failure to respond to initial treatment
- serious co-morbidites (eg. heart failure
- insufficient home support
What is the long-term prognosis after hospitalization?
5year mortality rate about 50%
What is the initial treatment of COPD exacerbation? what is the discharge from hospital?
Initial: Start SABA and LABA
Discharge: LABA and/or LAMA
When would you use systemic corticosteroids
When it is interfering with their daily activities
- 40mg/day f5d
When is antibiotic indicated in COPD exacerbations? (2)
increase in sputum AND
- increase in sputum volume OR
- increased dyspnea
- require mechanical ventilation
Which NRT has the fastest onset?
Nicotine spray
Which NRT has the most CV side effects
Nicotine patch
Bupropion
Purpose
Safety
Benefits
Purpose
- reduces withdrawal symptoms
Safety
- inc seizures, dec appetite (don’t use in malnourished patients)
Benefits
- use if they also have depression
Varenicline
Purpose
Safety
Purpose
- reduces withdrawal symptoms
- reduces cravings
- reduces pleasurable effects of tobacco
Safety
- only use in stable psychiatric patients
Which is more effective
- varenicline
- buproprion
- NRT patch alone
Vareniciline
Buproprion is more effective than combo NRT T/F
False
- burporion is similar to single NRT, LESS effective than combo NRT
What medications are indicated for COVID-19 patients with COPD exacerbations (2)
- systemic steroids
- Antibiotics
