1 - COPD

Question 1

Definition of COPD

Answer 1

• Chronic (progressive, non-curable)
• Obstructive (blockage)
• Pulmonary (lungs)
• Disease

Question 2

How is COPD diagnosed?

Answer 2

• Symptoms
• History – smoking or other exposures, other lung disease
• Spirometry (obstruction and/or restriction that isn’t reversible = COPD)
• *No screening w/o sx

Question 3

Step 1 for COPD tx. Give examples

Answer 3

• Short acting bronchodilator; can be SAMA (muscarinic) or SABA (beta)
• Short acting muscarinic antagonist (SAMA) = ipratropium
• Short acting beta agonist (SABA) = salbutamol

Question 4

Compare and contrast SAMA vs. SABA

Answer 4

• Equivalent efficacy in COPD
• • Improves sx, not exacerbations
• Schedule = QID then PRN
• Salbutamol cheaper
• Only MDI (requires aerochamber)

Question 5

Step 2 for COPD tx. Give examples

Answer 5

• Long acting bronchodilators; can be LAMA (muscarinic) or LABA (beta)
• Long acting muscarinic antagonists (LAMA) = glycopyrronium, tiotropium, aclidinium, umeclidinium
• Long acting beta agonists (LABA) = salmeterol, indacaterol, formoterol
• LAMA slightly better than LABA, so preferred for step 2 but depends on pt preference or cost

Question 6

Compare and contract short acting vs. long acting bronchodilators

Answer 6

• LAMA decreases exacerbations (~1 less exacerbation in 4 years), hospitalizations, adverse effects, and increases QOL
• LABA decreases sx and increases QOL and FEV1
• • Smaller decrease in exacerbations vs. LAMA
• Schedule = OD or BID vs. QID
• Increased cost vs. SABD
• Devices = more variety, no aerochamber

Question 7

Examples of LAMA + LABA inhalers

Answer 7

• Glycopyrronium + indacaterol
• Umeclidinium + vilanterol,
• Aclidinium + formoterol
• Tiotropium + oladaterol

Question 8

Compare and contract LAMA vs. LAMA + LABA

Answer 8

• Efficacy vs LAMA = no difference in exacerbations, hospitalizations, or mortality; statistically significant increase in QOL (but not clinically significant on average); FEV1 increased by 0.06
• Schedule = mostly OD
• Increased cost
• Devices = same variety (pt can try the inhaler & see if it helps their sx & then decide if the cost is worth it)

Question 9

Describe the FLAME trial

Answer 9

• Studied LAMA + LABA vs. LABA + ICS x 1 year

- Results = LAMA + LABA better than LABA + ICS (less exacerbations, rescue puffs, & pneumonia)

Question 10

Describe the INSTEAD trial

Answer 10

• Intervention:
• • Salmeterol/fluticasone x 3 or more months
• • Then continue ICS + LABA or change to just LABA (indacaterol) for 6 more months
• Results = LABA monotherapy no worse than LABA + ICS

Question 11

Describe the WISDOM trial

Answer 11

• Intervention:
• • Salmeterol + tiotropium + fluticasone (LABA/LAMA/ICS) x 6 weeks
• • Then continue triple therapy, or taper off fluticasone (over 12 weeks)
• • Then LAMA/LABA vs. LAMA/LABA/ICS x 1 year
• Results = in px on LAMA/LABA tapering off ICS didn’t change outcomes

Question 12

Describe the IMPACT trial

Answer 12

• LAMA/LABA/ICS vs. LAMA/LABA or LABA/ICS x 1 year
• Included px w/ asthma (steroids are 1st line for asthma, so obviously will help)
• Results = triple therapy better than LABA + ICS in COPD px who also have asthma (not relevant)

Question 13

Summarizes the efficacy of the different tx for COPD

Answer 13

• SABA = improves sx
• LAMA = improves exacerbations (decrease by ~1 q4years), hospitalizations, QOL, and adverse effects
• LAMA + LABA = improves FEV1, unknown effect on sx
• LAMA + LABA + ICS = unknown if produces any improvement, increases risk of pneumonia

Question 14

What are some non-pharms for COPD?

Answer 14

• Quit smoking – decreases mortality by 40%, improves sx & lung function, improves QOL
• Vaccines – annual flu & pneumonia
• Physical activity
• CVD risk reduction where applicable (statins, BP meds)
• *All have a larger impact on hard outcomes (mortality, hospitalizations, QOL) than inhalers

Question 15

What is the benefit of pulmonary rehab?

Answer 15

• Provides education, smoking cessation, exercise training, nutrition counseling, psychosocial support
• For anyone w/ disabling COPD, can be referred by anyone
• Proven improvements in sx, exercise tolerance, & QOL

Question 16

Define a COPD exacerbation

Answer 16

Acute worsening of sx over > 48 h

Question 17

Describe the tx for a COPD exacerbation

Answer 17

1. Schedule SABD (salbutamol or ipratropium 2 puffs QID)
   - - Continue maintenance inhalers
   - - +/- oxygen
2. Systemic steroids (prednisone 50 mg x 5 days)
3. Sometimes antibiotics (if change in sputum colour and increased sputum volume or increased dyspnea)

Question 18

Describe the use of systemic steroids for COPD. Efficacy, benefit, and is tapering required?

Answer 18

• Efficacy = increases FEV1 and decreases tx failure
• Largest trial (SCOPE) showed largest FEV1 benefit at 3 days
• • 2 studies showed most effect in 5 days w/ little improvement beyond
• Tapering only required if using steroids > 14 days (will likely never have to taper for COPD exacerbations)

Question 19

Describe the use of antibiotics for COPD

Answer 19

• < 4 exacerbations/year = amoxicillin 1 g TID x 5-7 days or doxycycline 200 mg once, then 100 mg BID x 5-7 days
• 4 or more exacerbations/year OR failure of first line agents above OR antibiotics in past 3 months = amox/clav 875/125 BID x 5-10 days or cefuroxime 500-1000 mg BID x 5-10 days

Question 20

Describe the use of home O2 for COPD

Answer 20

• If O2 sats are low when maximized other therapy
• Absolutely can’t be a smoker (flammable)
• Efficacy = decreases sx & mortality and increases exercise
• • Also decreases QOL, very high cost, & many adverse effects

Question 21

What is included in palliative care for COPD and when is it used?

Answer 21

• When no longer worried about mortality, exacerbations or hospitalizations, but sx
  1. Oxygen (covered by Palliative care program)
  2. Opioids – decreases sensation of breathlessness; low dose (morphine 1 mg q1-2h prn)

Question 22

Summary/ tips for COPD

Answer 22

• COPD inhalers don’t make huge improvements, but may be important to px
• Pt preference is important in inhaler choice
• Combo inhalers can be great for cost & adherence, but only when both drugs are needed (add 1 at a time to assess true effect after 2-3 months)
• ICS rarely justified (unless asthma coexists)
• Continually re-educate and re-assess adherence and technique