Respiratory and GI Flashcards
Symptoms of COPD? (3)
- Dyspnea
- Chronic cough
- Increased sputum
How is COPD diagnosed? (3)
- Spirometry
- FEV1/FVC < 0.7
- Persistent
What should be assessed for in COPD patients? (6)
- PFTs
- Symptom characteristics/impact on function
- History of exacerbations
- Comorbidities
- Vaccination status
- Smoking status
What are the goals of therapy for COPD? (3)
- Improve exercise capacity and ability to perform daily activities
- Reduce symptoms
- Reduce exacerbations
What are the cornerstones of COPD treatment? (6)
- Encourage/support smoking cessation
- Influenza vaccine annually
- COVID vaccines per current guidelines
- Pneumococcal vaccine x1
- Pulmonary rehabilitation
- Long-term oxygen therapy for severe resting chronic hypoxemia (Pa02 < 55 mmgHg)
What COPD stage is MRC score 1?
What FEV1 is associated with it?
At risk
>80%
What COPD stage is MRC score 2?
What FEV1 is associated with it?
Mild
>80%
What COPD stage is MRC score 3 and 4?
What FEV1 is associated with it?
Moderate
50-80%
What COPD stage is MRC score 5?
What FEV1 is associated with it?
Severe or very severe
30-50% or <30%
What MRC score does this describe:
“I only get breathless with strenuous exercise”
1 (FEV1 >80%)
What MRC score does this describe:
“I get short of breath when hurrying on the level or walking up a slight hill”
2 (FEV1 >80%)
What MRC score does this describe:
“On level ground, I walk slower than people of the same age because of breathlessness, or I have to stop for breath when walking at my own pace on the level.”
3 (FEV1 50-80%)
What MRC score does this describe:
“I stop for breath after walking about 100 meters (~1 street block) or after a few minutes on level ground
4 (FEV1 50-80%)
What MRC score does this describe:
“I am too breathless to leave the house or I am breathless while dressing”
5 (FEV1 30-50% or <30%)
Bronchodilators are central to managing symptoms of COPD. What use do SABAs/SAMAs have? (3)
PRN use
- May be sufficient in very mild disease
- Combination superior to either alone
Bronchodilators are central to managing symptoms of COPD. What use do LABAs and LAMAs have? (4)
LABA and LAMA improve function, reduce dyspnea and exacerbations
- LAMAs have greater effect on reducing exacerbation risk
- Preferred over short-acting agents except in very mild disease
- Combination therapy greater symptomatic benefit and reduction in exacerbations than either alone
Name the SABAs (2)
- Salbutamol
- Terbutaline
Name the SAMA (1)
Ipratropium
Name the SABA + SAMA combo (1)
Salbutamol + Ipratropium (COMBIVENT)
Name the LAMAs (4)
- Tiotropium
- Aclidinium
- Glycopyrronium
- Umeclidinium
Name the LABAs (3)
- Salmeterol
- Formoterol
- Indacaterol
Name the LAMA + LABA combos (4)
- Umeclidinium + Vilanterol (Ellipta)
- Glycopyrronium + Indacaterol (Breezehaler)
- Tiotropium + Olodaterol (Respimat)
- Aclidinium + Formoterol (Genuair)
Name the LAMA+LABA+ICS combos (2)
- Umeclidinium + Vilanterol + Fluticaonse (TRELEGY)
- Glycopyrronium + Formoterol + Budesonide (BREZTRI)
True or False? ICS stops decline in FEV1 in COPD
False - ICS does not modify decline in FEV1 in COPD
ICS is a necessary component in pts with…
asthma/COPD
ICS use increases the risk of _________
pneumonia
Compare the following: ICS/LAMA/LABA combo vs. LABA+ICS vs. long-term oral steroids in COPD treatment
- ICS/LAMA/LABA triple therapy better than mono- or dual therapy in severe disease to reduce exacerbations and improve lung function
- LABA + ICS combo alone no longer recommended for COPD
- Long-term oral steroids not recommended
What constitutes group A and group B COPD?
0 or 1 moderate exacerbations (not leading to hospital admissions)
What is group A and group B COPD treatment?
Group A = bronchodilator
Group B = LABA + LAMA
What constitutes group E COPD?
> = 2 moderate exacerbations or >= 1 leading to hospitalization
What is group E COPD treatment? (3)
- LAMA + LABA
- May add SABA for breakdown symptoms
- Add ICS if:
- Blood eosinophils > 300
- Continued COPD exacerbations
What are 3 factors where we would be against adding ICS to long-acting bronchodilator in COPD?
- Repeated pneumonia events
- Blood eosinophils < 100 cells/uL
- History of myobacterial infection
What are the ADEs of inhaled beta-agonists? (3)
- Jittery
- Shaking
- Tachycardia
Generally well tolerated
What are the ADEs of antimuscarinics (COPD)? (2)
- Dry mouth
- Systemic ADEs uncommon, but possible for constipation
What are the ADEs of inhaled corticosteroids? (2)
- Thrush
- Hoarseness or changes in voice
Inhaler techniques impacts drug delivery and effectiveness. Explain that in terms of COPD in older adults (2)
- Up to 90% of older adults use inhaled device incorrectly
- Poor technique linked with poor symptom control and increased exacerbations
- Increased risk with older age, use of multiple device types, lack of education on how to use
- Assess inhaler technique before escalating treatment
- Lung Sask website has great patient education resources
Pick an inhaler for an older COPD patient using the hands vs. lungs approach:
What can you pick for someone with stronger hands and stronger lungs?
Any inhaler is likely appropriate. Cost and convenience may be the foremost considerations
Pick an inhaler for an older COPD patient using the hands vs. lungs approach:
What can you pick for someone with weaker hands and stronger lungs? (4)
- Turbuhaler
- Diskus
- Ellipta
- Genuair
Pick an inhaler for an older COPD patient using the hands vs. lungs approach:
What can you pick for someone with stronger hands and weaker lungs? (5)
- Breezehaler
- Handihaler
- Genuair
- MDI
- Respimat
Pick an inhaler for an older COPD patient using the hands vs. lungs approach:
What can you pick for someone with weaker hands and weaker lungs?
Genuair
Some LABAs and LAMAs are now first-line formulary options in SK. What are the EDS criteria for COPD pharmacotherapy? (3)
- LABAs and LAMAs for treatment of COPD
- LAMA+LABA combinations generally require inadequate symptom control on LABA or LAMA monotherapy
- TRELEGY (ICS/LABA/LAMA) requires inadequate response to combination LABA+LAMA inhaler or to replace triple therapy with separate inhalers
If using > 1 inhaler - try to limit to one ______ ____
device type
What are the once daily LAMAs and LABAs? (5)
LAMAs:
1. Tiotropium
2. Glycopyrronium
3. Umeclidinium
LABAs:
1. Indacaterol
2. Olodaterol
How to manage HF in COPD patient?
Use cardioselective beta-blockers, monitor impact on COPD symptoms
GERD and vitamin D deficiencies are associated with COPD _____________
exacerbations
What are some medications to avoid when possible in COPD? (4)
- Non-selective beta-blockers
- ACEIs - watch for cough
- BZDs and opioids
- 1st generation antihistamines, other oral anticholinergics
Why are exacerbations important? (3)
- Contribute to disease progression
- Hospital admissions –> functional decline
- Increased morbidity and mortality
AECOPD is the ______ most common cause of hospitalization in Canadian adults
second
What pharmacotherapy is used in COPD exacerbations? (5)
- SABA scheduled every 4-6 hours (+SAMA if needed)
- Oxygen therapy if needed (target O2 saturation 88-92%)
- Maintain background pharmacotherapy or escalate as needed (should not be used in place of short-acting bronchodilators as above)
- Systemic corticosteroids to improve FEV1, oxygenation, and shorten hospitalization (limit 5-7 days) (prednisone 30-50mg daily in AM)
- Antibiotics indicated if:
- Increased sputum purulence + at least one of: dyspnea or increased sputum volume
- Or need for mechanical ventilation
What antibiotics would be chosen for high risk AECOPD individuals? (3)
- Amoxi-clav
- Levofloxacin
- Moxifloxacin
(All other antibiotic treatments for AECOPD are for low-risk individuals)
What makes someone a high risk individual in acute exacerbation of COPD? (6)
- FEV1 <50% (i.e., severe COPD)
- Coronary artery disease
- Chronic oral corticosteroid use (e.g., RA)
- > =4 exacerbations per year
- Use of home oxygen
- Antibiotics used in last 3 months
Age-related changes in GI system increases prevalence of dyspepsia and GERD. What are these changes? (5)
- Poor esophageal clearance
- Lower esophageal sphincter dysfunction
- Hiatal hernia
- Delayed gastric emptying
- Increased intra-abdominal pressure
What are some possible dietary contributors to dyspepsia/GERD? (5)
- Caffeine
- Alcohol
- Tomatoes/tomato sauce, garlic, onions
- Spicy/fatty foods
- Chocolate, peppermint
What are some medication causes/contributors to dyspepsia/GERD? (9)
- NSAIDs
- Steroids
- Bisphosphonates
- Potassium
- Iron
- Opioids
- Anticholinergics
- Nitrates
- CCBs
What does VBAD stand for?
Vomiting, persistent
Bleeding anemia, melena (bloody stools - black or “tarry” in appearance)
Abdominal mass or unexplained weight loss e.g., 3kg or 10% body weight
Dysphagia (difficulty or discomfort in swallowing)
Presence of VBAD symptoms or new-onset symptoms after age 50 means pt should be ________ ___ _________
referred for endoscopy
What to know about NSAID use and GI toxicity?
Individuals at moderate risk for GI toxicity should receive GI prophylaxis with either a PPI (preferred) or misoprostol
- If high risk –> avoid NSAID (preferably) or use coxib + PPI
What are high risk factors for NSAID GI toxicity? (2)
- History of complicated ulcer, especially recent
- Multiple (>2) risk factors (from moderate risk list)
What are moderate risk factors for NSAID GI toxicity? (5)
(Moderate risk = 1-2 of these)
- NSAID use: high dose or multiple agents
- History of uncomplicated ulcer
- Older age >=60 years, >=70 years
- Concurrent ASA including low dose, corticosteroids, anticoagulant, or SSRIs
- History of CVD
When treating GERD/dyspepsia in older adults what should we do when feasible/practical?
Lifestyle measures
For mild symptoms of GERD/dyspepsia what can be used for treatment? (2)
- PRN antacids may be sufficient
- Calcium carbonate (Tums) 200-400mg prn
- Alginates (Gaviscon) 2-4 tsp four times daily prn
- Avoid aluminum and magnesium-containing antacids in older adults - H2RAs prn or once-twice daily scheduled
- Famotidine and ranitidine
- Require dosage adjustment in renal impairment to prevent anticholinergic adverse effects
When are PPIs first-line? (3)
- Moderate-severe GERD
- Erosive esophagitis
- To promote ulcer healing (recommended duration of therapy =4-8 weeks)
When might PPIs be used indefinitely? (3)
- Individuals with documented Barrett’s esophagus
- Grade 4 erosive esophagitis
- Previous GI bleed with continued risk factors
Consider trying to deprescribe chronic PPIs when?
Once per year in the absence of compelling indications
Constipation is often multifactorial. What are those factors? (4)
- Medical conditions
- Medications
- Pelvic floor dysfunction
- Slowed intestinal transit
What is secondary constipation?
May be due to medical conditions, medications, metabolic abnormalities
What are the alarm features of constipation? (8)
- Age over 50 with recent onset of symptoms
- Rectal bleeding or rectal prolapse
- Fever
- Significant weight loss
- Nocturnal symptoms
- Abnormal lab work (e.g., anemia or iron deficiency)
- Strong family history (bowel cancer, etc.)
- Palpable abdominal or rectal mass
Presence of alarm features in constipation, what do we do?
Physician consult to rule out an underlying condition (e.g., colorectal cancer)
What are 5 medication causes of constipation?
- Anticholinergics
- Opioids
- Iron
- Calcium
- CCBs (verapamil > diltiazem > DHP CCBs)
What are some non-pharm constipation management options? (4)
- Lifestyle recommendations first-line whenever feasible
- Physical activity as tolerated
- Adequate fluid intake
- Apple, pear, or prune juice
- Particularly important with bulk-forming laxatives e.g., psyllium
- Also helpful if using osmotic laxatives - Dietary fibre
- Soluble (psyllium) preferred over insoluble (e.g., bran) due to better tolerability
What are the osmotic laxatives? (3)
- PEG3350
- Lactulose
- Glycerin suppositories
What is the mechanism of osmotic laxatives?
Combined osmotic and local effect stimulates colonic peristalsis
What is the onset of oral osmotic laxatives and suppositories?
- 24-96 hours (usual oral dosing)
- 15-30 mins with glycerin suppositories or when PEG used as bowel prep
What is the bulk-forming agent for constipation?
Psyllium (metamucil) 3.4-6.8g daily-TID
What is the MOA of bulk-forming agents?
Dissolves or swells in intestinal fluid and forms a gel which facilitates stool passage
What to know about bulk-forming agents? (3)
(That is, absorption, fluid, ADEs)
- Not absorbed systematically
- Requires sufficient fluid consumption to work (~250mL)
- ADEs = gas and cramping, potential for obstruction
What is the stool softener used in constipation?
Docusate
What is the MOA of docusate?
Anionic surfactant, facilitates wetting and passage of fecal material
(Limited value in the management of constipation)
When might docusate be useful?
ADEs?
- May be useful in situations where straining is to be avoided e.g., hemorrhoids, post-anorectal surgery
- Generally well-tolerated, can contribute to abdominal pain and cramps in higher doses
What are the saline laxatives?
Magnesium citrate/hydroxide/sulfate, sodium biphosphate
What is the mechanism of saline laxatives?
Non-absorbable cations and anions draw fluid into intestines –> increase intestinal motility
What is the indication for saline laxatives?
When acute bowel evacuation is required
- Should not be used for chronic constipation management due to potential for electrolyte losses and deficiences
What are the ADEs of saline laxatives?
Overdose or chronic use can lead to hypermagnesemia, hyperphosphatemia, abdominal cramping, nausea, vomiting, or edema
What are the 2 stimulant laxatives?
- Senna
- Bisacodyl (stronger stimulant than senna)
What is the MOA of stimulant laxatives?
Propulsive peristalsis, may stimulate secretion of water and electrolytes
What are the indications for stimulant laxatives?
Chronic medication-induced constipation (e.g., opioids)
What are the ADEs for stimulant laxatives? (3)
Cramping and abdominal pain, urine discoloration (senna)
- ?potential for long-term bowel dysfunction or pigmentation
- Nausea and vomiting if enteric coating compromised
