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IPFC 2 Final > COPD therapeutics > Flashcards

COPD therapeutics Flashcards

1
Q

What does the mMRC questionnaire ask for?

A

Description of breathlessness after exercise or normal activity
- Dyspnea

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2
Q

What factors are in the COPD assessment test (CAT)?

A

Both respiratory symptoms and functioning

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3
Q

Define group A COPD characteristics
Exacerbations?
mMRC score
CAT score

A

Exacerbations?
- 0 or 1 NOT LEADING TO HOSPITAL

mMRC score: 0-1
CAT score: under 10

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3
Q

Define group B COPD characteristics
Exacerbations?
mMRC score
CAT score

A

Exacerbations?
- 0 or 1 NOT LEADING TO HOSPITAL

mMRC score: 2+
CAT score: 10+

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4
Q

Define group E COPD characteristics
Exacerbations?
mMRC score
CAT score

A

Exacerbations?
- 2+ Moderate exacerbations
- 1+ LEADING TO HOSPITAL

mMRC score: 2+
CAT score: 10+

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5
Q

What is the BODE index used for? What are the factors?

A

To predict mortality
B= BMI
O = obstruction (FEV1)
D = Dyspnea (mMRC)
E = exercise capacity (distance walked in 6 min)

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6
Q

What do COPD exacerbations look like (3 main symptoms)

A

Acute changes in:
1. Cough increases in frequency + severity
2. Sputum production inc in volume / character
3. Dyspnea increases

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7
Q

What are the therapeutic strategies level in COPD (5)

A
  1. Smoking cessation , healthy lifestyle, SABA PRN
  2. Inhaled maintenance/preventative pharmacotherapies
  3. Pulmonary rehab
  4. Other pharmacotherapies
  5. Oxygen +/- NIV (non-invasive ventilation)
  6. Surgical/endoscopic therapy
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8
Q

When is pulmonary rehab recommended? what group of patients?

A

Prevents hospitalization if initiated less than 4 weeks after an exacerbation
- encouraged for Group B and E patients

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9
Q

SABA (2)
MOA
PD (side effects) (4)
Onset
Duration

A

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

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10
Q

SAMA (1)
MOA
PD (side effects) (3)
Onset
Duration

A

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

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11
Q

Is SAMA/SABA combo better than SAMA and SABA alone? What combination exists (1)

A

Combo more effective than single therapy
- attacking smooth muscle in 2 different ways

  1. Ipratropium + salbutamol
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12
Q

Can ICS be used alone in COPD?

A

Never

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13
Q

ICS (5)
MOA
PD (side effects) (3)
Onset
Duration (for clinical benefit)

A

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

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14
Q

LABA (4)
Onset
Duration

A

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

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15
Q

LAMA (4)
MOA
Onset
Duration

A

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

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16
Q

What are the LABA/ICS combo available for COPD? (3)
Which is the only combo with duration of 24 hours?

A
  1. Fluticasone prop/salmeterol ADVAIR diskus
    - generic: WIXELLA
  2. Budesonide/formoterol SYMBICORT
  3. fluticasone furoate/ vilanterol BREO ELIPTA

24 hour duration
- fluticasone furoate / vilanterol

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17
Q

What are the LAMA/LABA combos available (4)

A
  1. ume/vilanterol
  2. Aclidi/ formoterol
  3. Tio/olodaterol
  4. glyco/indacterol
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18
Q

What are these groups usually prescribed as initial treatment
Group A
Group B
Group E

A

Group A
- bronchodilator (LAMA is best)

Group B
- LABA/LAMA combo

Group E
- LABA/LAMA combo
- if eosinophils 300+ consider LABA/LAMA/ICS

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19
Q

What is the general rule based on patient’s current long-acting inhaler therapy? (2)

A
  1. Patient can always use a SABA
  2. If a patient on a LAMA –> dont use a SAMA
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20
Q

What do you give if a patient is neither on a LABA or LAMA

A

can give a SABA and/or SAMA

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21
Q

Is SABA/SAMA combo more effective for DYSPNEA for reliever than monotherapy

A

Yes, due to different
- sites of action
- mechanisms of action
- onset/durations of action

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22
Q

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?

A
  1. Short acting bronchodilator (SABA)
  2. Take duo therapy SABA/SAMA
  3. Choose a LABA or LAMA
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23
Q

Which is better for reducing dyspnea, exacerbations, FEV1, use of salbutamol: LABA or LAMA

A

LAMA

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24
Q

Is LABA effective as monotherapy. What was the outcome?

A

Yes
- decreased exacerbation
- decrease use in SABA
- improved FEV1

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25
Q

Can group A patients that have CV problems/complications start LAMA

A

Yes

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26
Q

In group B patients
1. is LABA/LAMA more effective than LABA
2. Is LABA/LAMA more effective than LAMA

A
  1. Yes
  2. No significance
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27
Q

Can you use LABA + ICS in group E COPD patients

A

never
- has more side effects than LABA/LAMA

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28
Q

What is the best treatment for Group E patients? When should you avoid ICS (3)?

A

LABA/LAMA/ICS

Against use of ICS:
- repeated pneumonia events
- eosinophils UNDER 100
- History of mycobacterial infection

29
Q

What was the outcome when using LABA/LAMA/ICS against LABA/LAMA? (1)

A

Triple therapy with high dose ICS reduced ALL-CAUSE MORTALITY compared to duo therapy

30
Q

Can you give triple therapy for patients with eosinophils below <150? Is it more effective than duo therapy?

A

Yes.
- same efficacy as duo therapy in eos <150

31
Q

When is ICS/LABA given? What if their symptoms or exacerbations get worse?

A

If patient has concomitant asthma
- if symptoms or exacerbations get worse, increase ICS/LABA dose or add LAMA

32
Q

What should you do if a COPD patient is on an ICS/LABA WITHOUT asthma

A
  • taper down ICS dose
  • switch to LABA/LAMA
33
Q

Which more effective at reducing exacerbations in GROUP E/mod-very severe patients: ICS/LABA or LABA

A

ICS/LABA

34
Q

Steroid use in COPD

A

Long-term NOT recommended (oral or inhaled)
- can use short-term

35
Q

If a patient is suffering from Dyspnea at FOLLOW-UP (not the first ABE treatment) what is the algorithm of treatment (3)

A
  1. LABA or LAMA
  2. LABA/LAMA combo
  3. Switch LABA/LAMA combinations
36
Q

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?

A
  1. LABA or LAMA
  2. LABA/LAMA if eos <300
  3. LABA/LAMA/ICS if eos 300+
37
Q

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+?

A

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

38
Q

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?

A
  1. Go to roflumilast (FEV1 < 50% & has chronic bronchitis) OR
  2. Azithromycin (former smoker)
39
Q

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+?

A

Taper OFF ICS dose (12 weeks)
- go back to LABA/LAMA

40
Q

What was the outcome of ICS tapering (12 weeks) vs ICS continuing

A

Tapering did not increase risk of exacerbation
- only resulted in a small drop of FEV1 and patient functionality

41
Q

Non-inhaled therapy: Roflumilast
Class
MOA
is it a bronchodilator?
Can give as single therapy?
Contraindication?
Efficacy?

A

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

42
Q

Azithromycin outcome
Efficacy
Safety

A

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

43
Q

What vaccines are recommended in COPD patients

A
  • Flu
  • COVID
  • Pneumococcal (PCV-20 preferred)
  • TdaP (tetanus, diphtheria, pertussis) (due to whooping cough)
  • Shingles (50+) (can get chicken pox in abdomen)
44
Q

What is Alpha-1-Antitrypsin augmentation indicated for?

A

Young patients with genetic deficiency of emphysema (stiff alveoli)

45
Q

What is vitamin D indicated for in COPD patients?

A

reduces exacerbations in patients with low baseline levels

46
Q

What are opioids indicated for in COPD patients?

A

In severe dyspnea when they are in palliative care
- causes respiratory drive –> makes them more comfortable instead of gasping for air all the time

47
Q

What type of inhalers use SLOW laminar inspiration and propellant?
What type of inhalers use Fast deep strong breath with no propellent?

A

Slow laminar (aersols) w/ propellant
- MDI
- Respimat

Fast deep strong breath with no propellent
- the rest

48
Q

Nebulizer efficacy w salbutamol

A
  • Early benefit at 5 min
  • No difference at 45 min
49
Q

If you have poor dexterity/coordination, which drug delivery method would you
Prefer?
Avoid?

A

Prefer
- DPI

Avoid
- Dry powder capsules
- Aerosols (MDI, respimat)

50
Q

If you have poor inspiratory force, which drug delivery method would you
Prefer?
Avoid?

A

Prefer (aerosols)
- MDI + nebulizer
- Respimat

Avoid
- DPI
- Dry powder capsule

51
Q

If you have many puffer types, which drug delivery method would you
Prefer?
Avoid?

A

Prefer
- turbohalar
- MDI
- Diskus

Avoid
- MDI
- Dry powder capsule
- ellipta
- respimat

52
Q

How do you choose an inhaler delivery device within a class?

A

Solely based on MD & patient preference

53
Q

What bacteria grew in sputum sample of COPD (3)
Which are most common

A
  1. H. flu (most common grew)
  2. Pseudo aeruginosa (more likely in severe patients)
  3. Strep. pneumo
54
Q

What is the strongest predictor of having a future exacerbation

A

Having a history of exacerbations

54
Q

What are the most common causes of COPD exacerbations? (2)

A
  • having a respiratory tract infection
  • air pollution
55
Q

Define exacerbation

A
  • increased dyspnea and/or cough + sputum that worsens in less than 14 days
  • can have tachypnea and/or tachycardia
56
Q

Define mild exacerbations
Dyspnea VAS
RR
HR
Resting SaO2
CRP

A

Dyspnea VAS < 5
RR: < 24 breaths/min
HR: <95 bpm
Resting SaO2: 92%+ and change <3
CRP: <10mg/L

57
Q

Define moderate exacerbations
Meet how many criteria
Dyspnea VAS
RR
HR
Resting SaO2
CRP

A

Meets 3/5 criteria

Dyspnea VAS: 5+
RR: 24+breaths/min
HR: 95+
Resting SaO2: <92% and change 3%+
CRP: 10+mg/L

58
Q

Define severe exacerbations
Dyspnea VAS
RR
HR
Resting SaO2
CRP

A

Same as moderate

ABG show worsening hypercapnia and acidosis (PaCO2 > 45 mmHg and pH <7.35)

59
Q

What are indicators for hospitalization for exacerbations in COPD

A
  • 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
60
Q

What is the long-term prognosis after hospitalization?

A

5year mortality rate about 50%

61
Q

What is the initial treatment of COPD exacerbation? what is the discharge from hospital?

A

Initial: Start SABA and LABA
Discharge: LABA and/or LAMA

62
Q

When would you use systemic corticosteroids

A

When it is interfering with their daily activities
- 40mg/day f5d

63
Q

When is antibiotic indicated in COPD exacerbations? (2)

A

increase in sputum AND
- increase in sputum volume OR
- increased dyspnea

  • require mechanical ventilation
64
Q

Which NRT has the fastest onset?

A

Nicotine spray

65
Q

Which NRT has the most CV side effects

A

Nicotine patch

66
Q

Bupropion
Purpose
Safety
Benefits

A

Purpose
- reduces withdrawal symptoms

Safety
- inc seizures, dec appetite (don’t use in malnourished patients)

Benefits
- use if they also have depression

67
Q

Varenicline
Purpose
Safety

A

Purpose
- reduces withdrawal symptoms
- reduces cravings
- reduces pleasurable effects of tobacco

Safety
- only use in stable psychiatric patients

68
Q

Which is more effective
- varenicline
- buproprion
- NRT patch alone

A

Vareniciline

69
Q

Buproprion is more effective than combo NRT T/F

A

False
- burporion is similar to single NRT, LESS effective than combo NRT

70
Q

What medications are indicated for COVID-19 patients with COPD exacerbations (2)

A
  • systemic steroids
  • Antibiotics

IPFC 2 Final (6 decks)

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