COPD - MJ

Question 1

Are the following reversible or irreversible etiologies of airflow limitation in COPD?

• Presence of mucus and inflammatory cells and mediators in bronchial secretions
• Bronchial smooth muscle contraction in peripheral and central airways
• Dynamic hyperinflation during exercise

Answer 1

reversible

Question 2

Are the following reversible or irreversible etiologies of airflow limitation in COPD?

• Fibrosis and narrowing of airways
• Reduced elastic recoil with loss of alveolar surface area
• Destruction of alveolar support with reduced patency of small airways

Answer 2

Irreversible

Question 3

The following are sxs of what dz?

• Chronic and progressive dyspnea
• Cough
• Sputum production
• Wheezing and chest tightness
• Others – fatigue, weight loss, anorexia, syncope, rib fractures, ankle swelling, depression, anxiety

Answer 3

COPD

Question 4

What are the 7 goals of treatment for COPD? (According to GOLD guidelines)

Answer 4

1. Prevent disease progression
2. Relieve symptoms
3. Improve exercise tolerance
4. Improve overall health status
5. Prevent and tx exacerbations
6. Prevent and txcomplications
7. Reduce morbidity and mortality

Question 5

What are the 3 steps (in general) to determine drug therapy for COPD?

Answer 5

Step 1: Spirometrically confirmed dx: Post-bronchodilator FEV₁ (determine if pt is mild- very severe)

Step 2: Assessment of airflow limitation (questionnaires- CAT, mMRC, )

Step 3: Assessment of sxs/risk of exacerbations (ABCD assessment tool)

Question 6

Process used to determine drug therapy for COPD:

• Step 1: post-bronchodilator FEV1- what values of FEV₁ correspond to mild, moderate, severe and very severe ?

Answer 6

Question 7

Process used to determine drug therapy for COPD:

Which questionnaires are used in step 2 (choice of thresholds)

Answer 7

►COPD Assessment Test (CAT)

►Chronic Respiratory Questionnaire (CCQ® )

►St George’s Respiratory Questionnaire (SGRQ)

►Chronic Respiratory Questionnaire (CRQ)

►Modified Medical Research Council (mMRC) questionnaire

Question 8

What are COPD exacerbations defined as?

Answer 8

an acute worsening of respiratory symptoms that result in additional therapy

Question 9

How are mild COPD exacerbations treated?

Answer 9

w/ SABDs only

Question 10

How are moderate COPD exacerbations treated?

Answer 10

SABDs + antibiotics/oral corticosteroids

Question 11

How are severe COPD exacerbations treated?

Answer 11

• patient requires hospitalization or visits the ER
• Severe exacerbations may also be associated with acute respiratory failure.

Question 12

Step 3: Assessment of exacerbation risk-

Blood _______ count may also predict exacerbation rates (in patients treated with LABA without ICS).

Answer 12

eosinophil

Question 13

ABCD assessment tool

Answer 13

Question 14

What is initial pharmacotherapy for a COPD pt in group A? (less sxs, low risk)

Answer 14

SABA

Question 15

What is initial pharmacologic tx for a COPD pt in group B? (more sxs, low risk)

Answer 15

LABA or LAMA

Question 16

What is initial pharmacologic tx for a COPD pt in group C? (Low sxs, high risk)

Answer 16

LAMA

Question 17

What is initial pharmacologic tx for a COPD pt in group D? (more sxs, high risk)

Answer 17

LAMA

or

LAMA + LABA

or

ICS + LABA (consider if eos>200)

Question 18

Tx for COPD exacerbations

Question 19

What is the onset and duration of bronchodilators- beta agonist (ex: albuterol)

Answer 19

Onset- 5 min

Duration- 2-6hrs

Question 20

T/F: the response to bonchodilators-beta agonists (ex: albuterol) is generally less than that seen in asthma

Answer 20

True

• only a sm improvement in FEV1

Question 21

Bronchodilators- beta agonists (ex: albuterol) may improve what 2 things?

Answer 21

1. Respiratory sxs
2. Exercise tolerance

Question 22

Long acting bronchodilators: both beta agonists and antimuscarinics:

• _____ outcomes in lung function as measured by spirometry
• symptoms including ______
• reductions in exacerbation frequency
• improved quality of life

Answer 22

• Superior
• dyspnea

Question 23

What are the ADEs of bronchodilators- beta agonists?

Answer 23

• sinus tachycardia, rhythm disturbances in predisposed patients
• skeletal muscle tremors can occur initially but subside as tolerance develops

Question 24

Is Ipatropium a short acting or long acting anti-muscarinic bronchodilator?

Answer 24

shor-acting

Question 25

Is tiotropium a short acting or long acting anti-muscarinic bronchodilator?

Answer 25

Long-acting

Question 26

What is the MOA of antimuscarinic bronchodilators?

Answer 26

Bronchodilation by competitively inhibiting cholinergic receptors in bronchial smooth muscle * Activation of M1 and M3 receptors by acetylcholine results in bronchoconstriction * Activation of M2 receptors inhibits further acetylcholine release

Question 27

The following describes the short acting or long acting antimuscarinic bronchodilators? ## Footnote * **Slower onset** of action (10-20 min) and a **more prolonged bronchodilator effect** vs. albuterol * **Does not affect the progressive decline in lung function**

Answer 27

Short acting

Question 28

The following describes the short acting or long acting antimuscarinic bronchodilators? ## Footnote * Significantly **greater improvements in lung function**, **quality of life** and **reduces the frequency of exacerbation** and need for hospitalization * Equal or superior efficacy compared with LABAs in various studies * Lower overall risk of mortality, including deaths from respiratory and cardiac causes

Answer 28

Long acting

Question 29

What are the 3 ADEs of antimuscarinic (anticholinergic) bronchodilators?

Answer 29

1. Dry mouth 2. Nausea 3. Occasional metallic taste

Question 30

The following are examples of what type of therapies? ## Footnote * Stiolto Respimat - tiotropium bromide/olodaterol * Anoro Ellipta - umeclidinium bromide/vilanterol * Bevespi Aerosphere - glycopyrrolate and formoterol * Utibron Neohaler - glycopyrrolate/indacaterol)

Answer 30

Combination therapies of LAMA + LABA

Question 31

What is the antiinflammatory mechanisms of corticosteroids?

Answer 31

* reduction in capillary permeability to decrease mucus * inhibition of release of proteolytic enzymes from leukocytes * inhibition of prostaglandins

Question 32

What are the 5 ADEs of _systemic_ corticosteroid therapy? Why might this be used in COPD?

Answer 32

1. Osteoporosis 2. Muscular atrophy 3. Thinning of the skin 4. Development of cataracts 5. Adrenal suppression/insufficiency ? clinical benefit including slowing of disease progression

Question 33

T/F: There is a role of ICS therapy for patients with **severe or very severe COPD and at high risk of exacerbation**

Answer 33

TRUE

Question 34

LABA & ICS have greater improvements in clinical outcomes such as what 3 things?

Answer 34

1. FEV1 2. Health status 3. Frequency of exacerbations

Question 35

The following are examples of what type of meds? * salmeterol plus fluticasone * budesonide plus formoterol * mometasone plus formoterol

Answer 35

LABA & ICS | (-sone or -sonide= corticosteroids)

Question 37

**Once-Daily Single Inhaler Triple Therapy for COPD: LABA + LAMA + ICS--\>** This inhaler provides better or worse control than 2 or more individual drug inhalers?

Answer 37

Better

Question 38

What type of medication is Trelegy Ellipta

Answer 38

* A combination of an ICS, a LAMA, and a LABA * Delivered once daily in Ellipta dry powder inhaler

Question 39

Which phosphodiesterase is: ## Footnote •found in airway smooth muscle cells and inflammatory cells _•responsible for degrading cAMP_

Answer 39

Phosphodiesterase 4 (PDE4)

Question 40

What is indication for Romflumilast, a phosphodiesterase 4 inhibitor?

Answer 40

Indication: with bronchodilator therapy in the maintenance treatment of **severe or very severe COPD patients at high risk of exacerbation** (Groups C and D) and are **not controlled by inhaled bronchodilators**

Question 41

The following is the mechanism of which med? ## Footnote 1. _Selectively inhibit \_\_\_\_\__- leads to accumulation of cAMP w/in inflammatory/structural cells important in the pathogenesis of COPD 2. _Anti-inflammatory effects-_ _suppression of cytokine release_ and inhibition of lung infiltration by neutrophils and other leukocytes 3. _Pulmonary remodeling_ and _mucociliary malfunction_ are also attenuated

Answer 41

Phosphodiesterase 4 (PDE4) inhibitors

Question 42

What are the ADEs of PDE4 inhibitors? (8)

Answer 42

* HA, dizziness, insomnia * Diarrhea, **weight loss**, nausea, **decreased appetite** * Back pain

Question 43

When are PDE 4 inhibitors contraindicated?

Answer 43

in moderate to severe hepatic impairment

Question 44

What interaction do PDE 4 inhibitors have with Cimetidine?

Answer 44

May increase serum concentrations of the active metabolite(s) of Roflumilast.

Question 45

What interaction do PDE4 inhibitors have with Ciprofloxacin (systemic)?

Answer 45

May increase the serum concentration of Roflumilast

Question 46

What interaction do PDE 4 inhibitors have with immunosuppressants? What are the 2 exceptions?

Answer 46

Roflumilast may enhance the immunosuppressive effect of Immunosuppressants. Exceptions: Beclomethasone; Budesonide

Question 47

Why is it not recommended to use theophylline and roflumilast (a PDE 4 inhibitor) together for the management of COPD?

Answer 47

Both theophylline and roflumilast have similar mechanisms of action through inhibition of phosphodiesterases

Question 48

What is the indication for α1-Antitrypsin Replacement Therapy?

Answer 48

inherited AAT deficiency-associated emphysema

Question 49

What is the treatment for patients with inherited AAT deficiency-associated emphysema?

Answer 49

* focus on reduction of risk factors such as smoking, symptomatic treatment with bronchodilators * augmentation therapy with replacement AAT * weekly infusions of pooled human AAT * ? significant reduction in lung tissue loss and destruction

Question 50

What are the 5 A's in th 5 step strategy for smoking cessation program

Answer 50

Ask Advise Assess Assist Arrange

Question 51

What are the 6 first line pharmacotherapies for smoking cessation and what is the common complaints for each?

Answer 51

1. **Buproprion SR**- insomnia, dry mouth 2. **Nicotine gum**- sore mouth, dyspepsia 3. **Nicotine inhale**r- Sore mouth and throat 4. **Nicotine nasal spray**- nasal irritation 5. **Nicotine patches**- skin reaction, insomnia 6. **Varenicline (Chantix)**- Nausea, sleep disturbances (vivid dreams)

Question 52

What are 3 prevention/maintenance therapies for patients w/ COPD?

Answer 52

1. **Inhaler technique** assessed regularly. 2. **Influenza/pneumococcal vaccination** decreases the incidence of lower respiratory tract infections. 3. **Pulmonary rehabilitation i**mproves symptoms, quality of life, and physical and emotional participation in everyday activities.

Question 53

In COPD patients with severe resting chronic hypoxemia, what has been shown to improve survival?

Answer 53

long-term oxygen

Question 54

In patients with stable COPD and _resting or exercise-induced moderate desaturation,_ What treatment should be prescribed routinely?

Answer 54

**long-term oxygen treatment** However, individual patient factors must be considered when evaluating the patient’s need for supplemental oxygen.

Question 55

What are considered "cardinal symptoms", which are used in the staging of acute COPD exacerbations?

Answer 55

1. _Worsening of dyspnea_ 2. _Increase in sputum volume_ 3. _Increase in sputum purulence._

Question 56

Staging of acute exacerbations of COPD: What constitutes an exacerbation as Mild?

Answer 56

Mild (type 1)= 1 cardinal symptom plus at least 1 of the following: * URTI w/in 5 days * unexplained fever * increased wheezing * increased cough * increase in respiratory or heart rate \>20% above baseline (cardinal sx= worsening of dyspnea, increase in sputum volume and increase in sputum purulence)

Question 57

Staging of acute exacerbations of COPD: What constitutes an exacerbation as moderate (type 2) vs severe (type 3)?

Answer 57

* Moderate (type 2)= 2 cardinal sxs * Severe (type 3)= 3 cardinal sxs (cardinal sxs= worsening of dyspnea, increase in sputum volume and increase in sputum purulence)

Question 58

Therapeutic options for acute exacerbations of COPD: When are abx recommended?

Answer 58

If 2+ of the following are present: * Increased dyspnea * Increased sputum production * Increased sputum purulence

Question 59

Therapeutic options for acute exacerbations of COPD: Bronchodilators: β-Agonists also may ______ mucociliary clearance.

Answer 59

increase

Question 60

Therapeutic options for acute exacerbations of COPD: When should noninvasive mechanical ventilation be considered? When is it not appropriate?

Answer 60

* **Consider** for patients with **acute respiratory failure.** * **Not appropriate** for patients with **altered mental status**, **severe acidosis, respiratory arrest, or cardiovascular instability.**

Question 61

What is the recommended antimicrobial therapy in an aute COPD exacerbation in a patient w/: * Uncomplicated exacerbations * \<4 exacerbations per year * No comorbid illness * FEV1 \>50% of predicted

Answer 61

**Macrolide** (azithromycin, clarithromycin) (not recommended: TMP/SMX, amox, first gen ceph and erythromycin)

Question 62

What is the recommended antimicrobial therapy in an aute COPD exacerbation in a patient w/: * Complicated exacerbations: *  Age ≥65 and \>4 exacerbations per year *  FEV1 \<50% but \>35% of predicted

Answer 62

Amoxicillin/clavulanate

Question 63

What is the recommended antimicrobial therapy in an aute COPD exacerbation in a patient w/: * Complicated exacerbations with risk of P. aeruginosa *  Chronic bronchial sepsis *  Need for chronic corticosteroid therapy *  Resident of nursing home with \<4 exacerbations per year * FEV1 \<35% of predicted

Answer 63

Fluoroquinolone with enhanced pneumococcal and P. aeruginosa activity (levofloxacin)

Question 65

What is the best Fluoroquinolone against pseudomonas?

Answer 65

Ciprofloxacin

Question 66

Pneumococcal vaccine: Who is PCV13 recommended for?

Answer 66

* All adults \>65 * Adults \>19y/o with certain health conditions (ones that weaken the immune system- HIV, organ transplant, leukemia, lymphoma, and severe kidney disease)

Question 67

Pneumococcal vaccine: Who is PPSV23 recommended for?

Answer 67

* **All adults \>65** * **19- 64 years old w/ certain health conditions** (chronic illnesses like asthma, DM or alcoholism; HIV, etc) or who smoke cigarettes **•(in group child care, have chronic conditions)**

Question 68

Pneumococcal Vaccine: How long must you wait between giving PCV13 and PPSV23?

Answer 68

At least **1 year apart** (must give both)