34/35 - COPD Flashcards by Karlo Sison

Initial Treatment of Stable COPD

What Group & What Drug(s)?

0-1 Moderate Exacerbations
not leading to hospital admin
&
mMRC 0-1 // CAT <10
modified MRC Dyspenea Scale (QOL) // COPD Assessment Test (Symptoms)

Group A

ANY BRONCHODIALATOR

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Initial Treatment of Stable COPD

What Group & What Drug(s)?

0-1 Moderate Exacerbations
not leading to hospital admin
&
mMRC > 2 // CAT > 10
modified MRC Dyspenea Scale (QOL) // COPD Assessment Test (Symptoms)

Group B

LONG ACTING BRONCHODIALATOR

LABA = -TEROLs
Indaca-terol // Oloda-terol // Salme-terol // Formo-terol // Arfomo-terol

LAMA = -IUMs
+Glycopyrrolate // Tiotropium // Aclidinium // Umeclidinium

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Initial Treatment of Stable COPD

What Group & What Drug(s)?

> 2 Moderate Exacerbations OR > 1 leading to Hospitilization
&
mMRC 0-1 // CAT <10
modified MRC Dyspenea Scale (QOL) // COPD Assessment Test (Symptoms

Group C

*LAMA = -IUMs**
*+Glycopyrrolate** // Tiotropium // Aclidinium // Umeclidinium

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Initial Treatment of Stable COPD

What Group & What Drug(s)?

> 2 Moderate Exacerbations OR > 1 leading to Hospitilization
&
mMRC > 2 // CAT > 10
modified MRC Dyspenea Scale (QOL) // COPD Assessment Test (Symptoms

Group D

LAMA or LAMA + LABA or ICS + LABA

*LAMA = -IUMs**
*+Glycopyrrolate** // Tiotropium // Aclidinium // Umeclidinium
*LAMA + LABA**
*-IUMs** + -TEROLs
*ICS + LABA**
*-SONE** + -TEROLs

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Acute COPD Exacerbation

TREATMENT

Short Burst Corticosteroids

*PREDNISONE**
*40mg for 5-7 days**

Improves:

*spirometry / ABGs / Symptoms**
reduced RELAPSE rates @ 30 days*

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Risk Factors for COPD

Modifiable Risks

*TOBACCO Smoke**
*Occupational Dust // Air Pollution**

NON-modifiable Risks
ASTHMA
Impaired lung growth // Infections
Genetics - a1-antitrypsin Deficiency

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Diagnosis of COPD

SPIROMETRY

*Symptoms**
*Cough / Sputum** (Mucus) / Dyspnea SOB

Exposure to Risk Factors
Tobacco / Occupation / Pollution
A-1 Antitrypsin Levels

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Assessment of COPD Exacerbation Risk

“Acute Worsening of respiratory symptoms that result in ADDITIONAL THERAPY”

Mild vs Moderate vs SEVERE

Blood Eosinophil Count** may also _predict_ *exacerbation rates
-> for those patients treated with LABA w/o ICS

Mild = SABD ONLY

Moderate = SABDs + AntiBiotics +/- Oral Corticosteroids

SEVERE = requires HOSPITILIZATION or visits emergency room

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Important Health Maintenance for COPD

IMMUNIZATIONS

Flu Vaccine –> reduces Serious Illness + Death

ALL SMOKERS SHOULD RECEIVE
–> PNEUMOCOCCAL 23 VACCINE
if 65 y/o+ –> prevnar 13 then 1 year for PCV23
SUBQ or IM
Protects against 85% of INVASIVE Pneumococcal strains

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Important Health Maintenance for COPD

PULMONARY REHABILITATION

EXERCISE / STRENGTH Training

Education + Adequate Nutrition

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Important Health Maintenance for COPD

SMOKING CESSATION

MOST EFFECTIVE intervention STOPS & REDUCES progression of COPD

Varenicline
Renal Dosing, CrCL < 30 = 0.5mg QD, MAX 0.5mg BID

Bupropion SR
150mg f3d –> 150mg BID
CI with SEIZURES – Good for Weight Gain + Depression
Hepatic = 150mg QOD // Elderly or Renal = 150mg QD

*NRTs**
not covered by insurance typically*

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Albuterol - Levalbuterol

Type / ADR

SABA

Short Acting B2 AGONIST

not completely selective
ADRs:
↑HR & Contraction
HypoKalemia –> leg cramps

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Ipratropium

Type / ADRs

SAMA
Short-Acting Muscarinic ANTAGONIST

Atrovent HFA MDI
also comes in inhalation solution - 15 min onset of action

ADR:
DRY MOUTH / ↑CV Events
Metallic taste / Blurred Vision
Urinary Retention / Tachycardia

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Which LAMA is considered the GOLD STANDARD?

LAMA = -IUMs + Glycopyrrolate

TIOTROPIUM
Spiriva Respimat

Glycopyrrolate –> Improved FEV1 > Tiotropium

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LAMA
Tiotropium / Aclidinium / Umeclidinium / +Glycopyrolate

USES

Effects on Exacerbations?

LAMA

*PREVENTS_ & _TREATS**
*Exacerbations**

Relieves symptoms / prevents hospitalizations

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LAMA
Tiotropium / Aclidinium / Umeclidinium / +Glycopyrolate

ADR / PRECAUTIONS

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ADR’s are the SAME as SAMA = Ipatropium
Dry mouth / blurred vision / constipation / urinary retention / glaucoma
EXCEPT:
does NOT show increase in CV EVENTS

CI:
Glaucoma / Prostatic HYPERplasia / Renal Impairment CrCl <50 mL/min

Combination SABA/SAMA

Advantages

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Albuterol + Ipratropium = Combivent

Combo provides greater change in spirometry than either agent alone.

Improved adherence & Cost

disadvantage
FIXED DOSE

Which LABAs are INHALATION SOLUTIONS?

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FORMO-TEROL** & **ARFORMO-TEROL

both 1 vial BID

Salmeterol is DPI dosed BID

Which LABAs are
ULTRA-LONG-ACTING
“Dosed DAILY”

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*INDACATEROL**
*1 CAP for inhalation DAILY,** ArCAPta Neohaler DPI
*OLODATEROL**
*2 Inhalers DAILY**, Striverdi Respimat

Salmeterol is DPI dosed BID

LABA = -TEROLs
Indaca-terol // Oloda-terol // Salme-terol // Formo-terol // Arfomo-terol

USES - Effect on exacerbations?

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*Prevent Exacerbations ONLY**
does NOT TREAT* compared to LAMA

Prevent Hospilizations / Relieve Symptoms

LABA = -TEROLs
Indaca-terol // Oloda-terol // Salme-terol // Formo-terol // Arfomo-terol

SIDE EFFECTS

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DPI - DRY COUGH

BLACK BOX WARNING
increased risk of ASTHMA-related deaths
never used ALONE for ASTHMA patients

Insomnia / Tremors / Palpitations

TachyCardia / QT Interval Prolongation / HypoKalemia

When would we ADD an ICS for COPD?

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LABA + ICS

for EXACERBATIONS:
EOS > 300
or EOS > 100 + > 2 moderate exacerbation / 1 hospitilization

Since:
COPD during EXACERBATIONS = EOSINOPHILIC INFLAMMATION

Eosinophils & COPD

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COPD is mainly NEUTROPHILIC Inflammation,
EXCEPT:
During EXACERBATIONS –> EOSINOPHLIC
&
pt with ASTHMA + COPD

Eosiniphils are associated with:
↑Risk of COPD exacerbations
↓Lung Function

Which LABA/ICS combination is dosed DAILY?

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*Fluticasone Furoate / Vilanterol**
*Breo Ellipta DPI**

1 Inhalation DAILY

**When would we INITIALLY use** **LABA/ICS Combination?**

**_ASTHMA_** + **COPD** or **GROUP D + _EOS**_ _**\>_** **300** _\>_ 2 Moderate Exacerbations OR _\>_ 1 leading to Hospitilization & mMRC _\>_ 2 // CAT _\>_ 10

**When would we use** **LABA + LAMA + ICS** Fluticasone furoate/Umeclidinium/Vilanterol Trelegy Ellipta - QD

**_STEP-UP_** for: **LABA+LAMA** when **EOS _\>_ 100** or **LABA+ICS** and **continued Exacerbations**

**ICS** - **ADRs** **ICS is NEVER used ALONE for COPD** **Budesonide**/ Formoterol **Fluticasone** Propionate/ Salmeterol Fluticasone propionate/ Salmeterol Fluticasone propionate/ Salmeterol Fluticasone Furoate/ Vilanterol

**_PNEUMONIA_** *not DOSE dependent, specific risk factors:* current smokers, prior pneumonia, BMI \<25 kg/m2, FEV1≥30%-\<50%, poor MRC dyspnea score) ## Footnote **_CANDIDIASIS_** **Dysphonia / Osteoporosis / Cataracts**

**RISK FACTORS** **for PNEUMONIA with ICS**

*NOT dose Dependent* **Prior exacerbation or Pneumonia** CURRENT **Smoker** **\> 55 y/o** **BMI \< 25** **FEV _\>_** **30-50%** **Blood Eosinophil \< 2%**

**Phosphodiesterase-4 Inhibitors** **Drug / Function**

**RFLUMILAST** = Daliresp ↑**cAMP** in **immunomodulatory/inflammatory cells** VV **Relax Airways** & ***supresssion*** of **Smooth muscle mitogenesis** *SUPRESSES:* **_↓NEUTROPHILS_** / **Macrophages** / **CD8 T-cells**

**When would we use a** **PDE4 Inhibitor = Roflumilast**

**_STEP UP_** for **LABA+LAMA** *but _EOS \< 100_* **_ADD-ON Therapy_** for **FEV1 \<50%** + **Chronic Cough/Sputum** (**bronchitis**) **1 hospitilization in past year** *NOT USED FOR EMPHYSEMA* **250 mcg PO QD f4 weeks** --\> **500 mcg PQ QD**

**PDE4 INHIBITOR = Roflumilast** **ADRs**

**Very common side effects --\> Need to TITRATE DOSE** 250 mcg QD for 4 weeks --\> 500 mcg PO QD **_Diarrhea**_ + _***Weight Decrease*_** + **Nausea** + **Depression** Metabolism: **_CYP3A4_**

**Macrolide Anti-Inflammatory** **Antibiotics** for COPD ## Footnote **Drugs / MoA**

**_Azithromycin**_ or _**Erythromycin_** ↓**Mucus+Sputum Production** * INHIBIT:* * *IL-1 / IL-6 / IL-8 / TNF-a** * *oxygen radical production of Neutrophils** * Prevent* **breakdown of neutrophils** --\> *release TOXIC substances* * IMPAIR* **migration of neutrophils**

**When would we use in COPD** **Macrolide Anti-Inflammatory Antibiotics?** **& Limitations**

**_Step Up:_** **FORMER SMOKERS** (*no longer smoking)* **SEVERE COPD + Multiple Exacerbations** Adherence to Bronchodilator & Anti-inflammatory Meds Limitations: **Hearing Loss / QT interval Prolongation** **BACTERIAL RESISTANCE**

**COPD Monitoring**

**Quarterly = CAT** (COPD Assessment Test) **Yearly = Lung Function Test** Every Visit: Smoking Status / Symptoms / Dosing / Adherence Technique / Exacerbations / Excercise

**Acute COPD Exacerbations**

_Causes:_ UNKNOWN / Viral / Air Pollution / Bacterial _Rule Out:_ **Pneumonia / CHF** / Arrhythmia / Pneomothorax / PE **Symptoms: ↑****Breathlessness** / **Wheezing / Chest Tightness** ↑**Cough+Sputum** **Fever / Change in Color-Tenacity Sputum**

**Home Management of Acute COPD Exacerbation**

**_INTENSIFY Bronchodilator Regimen_** Nebulization -\> dose more regularly Albuterol / Ipratropium MDI --\> 4-8 puffs Duoneb --\> more doses **_ORAL CORTICOSTEROIDS_** Prednisone 40mg for 5-7 days **_Consider ANTIBIOTICS_** 3 of the following: ↑Dyspnea / ↑Sputum Volume / ↑_Sputum Purulence_

**When to consider ANTIBIOTICS?** for **Acute COPD Exacerbation** –Azithromycin or Clarithromycin –Doxycycline –Trimethoprim/sulfamethoxazole –Cefuroxime, cefpodoxime, cefdinir –Moxifloxacin, levofloxacin –Amoxicillin-clavulanate

**requires _Mechanical Ventilation_** or **_3 of the following symptoms_**: ↑**Dyspnea** ↑**Sputum Volume** ↑**_Sputum PURULENCE_** ***only need 2* if 1 is sputum purulence**

**Long Term Oxygen Therapy COPD** **MoA / Efficacy**

Main cause of death in COPD **CV disease / Lung Cancer / Respiratory Failure** MoA: Modest yearly ***decline* in pulmonary artery pressure** *REVERSES* **secondary polycythemia** ↑**cardiac function test during rest & exercise** Efficacy: ↑**Survival / QOL / Exercise tolerance ↑Judgement + Short Term Memory**

34/35 - COPD Flashcards

(38 cards)