lectures 29-30 (COPD treatment) Flashcards
exam 3
COPD diagnosis
symptoms support diagnosis, but spirometry is required for diagnosis
- dyspnea
- cough +/- sputum production
- wheezing
- chest tightness
- fatigue
- activity limitation
spirometry
FEV1: amount of air that can be forcefully exhaled in one second
FVC: maximum amount of air that is exhaled after taking a deep breath
- COPD dx is consistent with FEV1/FVC < 0.7 (or 70%)
goals of therapy
reduce symptoms
- relieve symptoms
- improve exercise tolerance
- improve health status
reduce risk
- prevent disease progression
- prevent and treat exacerbations
- reduce mortality
assessment of COPD
COPD assessment test (CAT)
modified medical research council (mMRC)
- collection of both CAT and mMRC essential for most accurate pharmacologic medication selection
SABAs
albuterol
- ProAir
- Proventil
- Ventolin
levalbuterol (xopenex)
LABAs
arformoterol (brovana)
formoterol (perforomist)
olodaterol (striverdi)
salmeterol (serevent)
SAMAs
ipratropium (atrovent)
LAMAs
tiotropoum (spiriva)
umeclidinium (incruse)
muscarinic antagonist side effects
dry mouth
uRTI
cough
bitter taste
blurred vision
group A
criteria:
- mMRC 0-1, CAT <10
- 0-1 moderate exacerbations not leading to hospital admission
treatment:
- bronchodilator
- improvement in
breathlessness
- can be long acting or short acting (long acting preference)
group B
criteria:
- mMRC >2, CAT >10
- 0-1 moderate exacerbations (not leading to hospital admission)
treatment:
- LABA + LAMA
- tiotropium/olodaterol (stiolto)
- umeclidinium/vilanterol (anoro)
group E
criteria:
- >2 moderate exacerbations
OR
- >1 leading to hospitalization
- consider LABA+LAMA+ICS if blood eos >300
treatment:
- tiotropium/olodaterol (stiolto)
- umeclidinium/vilanterol (anoro)
- dual long-acting bronchodilator therapy > monotherapy for reducing exacerbation risk
- use of ICS/LABA not encouraged –> escalation to LABA/LAMA/ICS if there is an indication for ICS therapy
- effect of ICS on exacerbation prevention likely only if blood eos. >300
GOLD guideline changes
group A:
- a bronchodilator
- mMRC 0-1, CAT <10
- 0 or 1 moderate exacerbations not leading to hospital admission
group B:
- LABA or LAMA
- mMRC >2, CAT >10
- 0 or 1 moderate exacerbations not leading to hospital admission
group C:
- LAMA
- mMRC 0-1, CAT <10
- >2 moderate exacerbations or >1 leading to hospitalization
group D:
- LAMA or LAMA+LABA or ICS+LABA
- mMRC >2, CAT >10
- >2 moderate exacerbations or >1 leading to hospitalization
role of ICS in COPD
strongly favors use:
- history of hospitalization(s) or exacerbation(s) in COPD
- >2 moderate exacerbations of COPD per year
- blood eosinophils >300
- history of or concomitant asthma
favors use:
- 1 moderate exacerbation of COPD per year
- blood eosinophils 100 to < 300
against use:
- repeated pneumonia events
- blood eosinophils <100
- history of mycobacterial infection
follow-up treatment for dyspnea
LABA or LAMA –> LABA + LAMA
- consider switching inhaler device or molecules
- implement or escalate non-pharmacological treatment(s)
- consider adding ensifentrine
- investigate and treat other causes of dyspnea
follow-up treatment for exacerbations
LABA or LAMA –> LABA + LAMA or LABA + LAMA + ICS –> rofumilast (FEV < 50% and chronic bronchitis), azithromycin (preferred in former smokers), dupilumab (chronic bronchitis)
PDE-4i
roflumilast (daliresp)
- dosing: 250mg PO daily x 4 weeks, then increase to 500mg PO daily
- 4 week 250mg period intended to increase tolerability; not considered a therapeutic dose
- cautioned use in those with moderate to severe liver impairment
- most common side effects: diarrhea, weight loss, nausea, decreased appetite, HA, insomnia
IL-4 receptor antagonist
dupilumab (dupixent)
- dosing: 300mg SC every other week
- hypersensitivity reactions: skin rash, erythema (usually in the first hour of admin. but can appear 1 month after initiation)
- dermatologic reactions: alopecia, psoriasis (delayed; can appear anywhere from first month of therapy to >1 year after initiation
