COPD therapeutics Flashcards by Pierre Wadeie

What does the mMRC questionnaire ask for?

Description of breathlessness after exercise or normal activity
- Dyspnea

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

Both respiratory symptoms and functioning

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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

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Define group B COPD characteristics
Exacerbations?
mMRC score
CAT score

Exacerbations?
- 0 or 1 NOT LEADING TO HOSPITAL

mMRC score: 2+
CAT score: 10+

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Define group E COPD characteristics
Exacerbations?
mMRC score
CAT score

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

mMRC score: 2+
CAT score: 10+

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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)

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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

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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

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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

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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

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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

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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

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Can ICS be used alone in COPD?

Never

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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

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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

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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

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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

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What are the LAMA/LABA combos available (4)

ume/vilanterol
Aclidi/ formoterol
Tio/olodaterol
glyco/indacterol

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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

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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

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

can give a SABA and/or SAMA

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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

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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

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

LAMA

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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

1. Yes 2. 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)

1. LABA or LAMA 2. LABA/LAMA combo 3. 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?

1. LABA or LAMA 2. LABA/LAMA if eos <300 2. 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?

1. Go to roflumilast (FEV1 < 50% & has chronic bronchitis) OR 1. 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

1. H. flu (most common grew) 2. Pseudo aeruginosa (more likely in severe patients) 3. 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