COPD Pharm

Question 1

SABA side fx

Answer 1

tremor (particularly in the hands, usually disappears as treatment continues), cardiac arrhythmias (more likely in susceptible patients), tachycardia, restlessness, headache, muscle cramps, and nervousness.
- Use cautiously in patients with cardiovascular disorders (e.g., coronary insufficiency, arrhythmias,
hypertension)

Question 2

SAMA side fx

Answer 2

headache, throat irritation, cough, dry mouth, GI motility disorders, dizziness, bitter/metallic taste. Use cautiously and monitor for worsening urinary
retention in patients with preexisting urinary tract obstruction.
• Use cautiously in patients with narrow angle glaucoma.
SAMA an LAMA should not be used concurrently

Question 3

Strong support for initiating ICS with these factors (4)

Answer 3

• history of hospitalization(s) for AECOPD
• > 2 moderate AECOPD per yr
• blood eosinophils >300 cells/uL
• hx of or concomitant asthma

Question 4

Consider use of ICS (2)

Answer 4

• 1 mod AECOPD per year

- blood eosinophils 100-300

Question 5

Against Use of ICS (3)

Answer 5

-repeated pneumonia event
-blood eosinophils <100
-history of mycobacterial
infection

Question 6

ICS benefits?

Answer 6

For persistent exacerbations or breathlessness , not for mono-therapy
- Use lowest effective dose
- Regular treatment improves symptoms, lung function and QoL, reduces frequency of
exacerbations in patients with FEV1<60% predicted

Question 7

ICS side fx

Answer 7

Oropharyngeal candidiasis (thrush), dysphonia, sore mouth, sore throat

● Systemic SE of long term treatment with high dose ICS

Question 8

Step therapy

Group A (MMRC 0-1, CAT<10, 0-1 exac)
what is initial therapy?
next step?

Answer 8

• A SABD (prn) or LABD

- Continue if symptomatic benefit documented D

Question 9

Step therapy

Group B (MMRC >/= 2, CAT >/= 10, 0-1 exac)
what is initial therapy?
next step?

Answer 9

LABA or LAMA (no evidence for one class over another)

• If persistent symptoms on mono therapy then LABA +LAMA
• If no response on combostep back to 1 & assess comorbidities

Question 10

Step therapy

Group C (MMRC 0-1, CAT< 10, >= 2 or >= 1 leading to hospital admin exac)
what is initial therapy?
next step?

Answer 10

LAMA (superior to LABA in this grp)

• If persistent exacerbations step up to LABA+LAMA
• LABA/ICS if asthma/COPD overlap

Question 11

Step therapy

Group D (MMRC >=2, CAT >/= 10, >= 2 or >= 1 leading to hospital admin exac)
what is initial therapy?
next step?

Answer 11

LAMA or LABA+LAMA or ICS + LABA*
* Consider if eosinophil count 300

• if persistent exacerbations step up to LABA+ICS+LAMA
• if on LABA/ICS step up to LABA+ICS+LAMA

Question 12

Oral corticosteroids: Prednisone

see side fx

Answer 12

• Long term treatment with oral corticosteroids should not be used in COPD
• absence of benefit in most patients and the high risk of adverse systemic effects
  short-term AECOPD

Question 13

Phosphodiesterase inhibitors: Roflumilast (Daxas®)

Answer 13

Non-steroid anti-inflammatory; Role not entirely clear
- Add-on therapy to bronchodilator treatment
o maintenance treatment of severe COPD associated with chronic bronchitis
o History frequent AECOPD

Question 14

Oral/iv methylxanthines

Theophylline oral/aminophylline intravenous

Answer 14

Place in therapy: Not first or second line, but considered as “another possible treatment” for managing stable COPD.
▪ Side effects: nausea, vomiting, abdominal cramps, headaches, nervousness, tremor, insomnia, tachycardia, tachypnea, seizures, coma, respiratory depression

Question 15

define AECOPD = lung attack

causes?

Answer 15

An acute event characterized by a worsening of symptoms (dyspnea, cough, sputum production) that is beyond normal day to day variation, is acute in onset, and leads to a change in regular medications

causes
● Infection
● Air pollution
● 1/3 no cause
● Other: pleural effusion, heart failure, pulmonary embolism, pneumothorax

Question 16

Consequences of AECOPD

see signs and symptoms

Answer 16

● Increased mortality
● Negative impact on QoL
● Accelerated lung function decline
● Impact on symptoms and lung function
● Increased economic costs

Question 17

AECOPD Classification

3 cardinal symptoms

Answer 17

Cardinal symptoms include:
● worsening of dyspnea,
● increase in sputum volume
● increase in sputum purulence

Question 18

AECOPD Classification

mild?
how to treat?

Answer 18

1 cardinal symptom plus at least 1 of the following URTI within 5 days

• fever without other explanation
• increased wheezing
• increased cough
• increase in respiratory or heart rate >20% above baseline:

Treated with SABD only

Question 19

AECOPD Classification

moderate?
how to treat?

Answer 19

2 cardinal symptoms

Treated with steroids +/- ABX

Question 20

AECOPD Classification

severe?
how to treat?

Answer 20

3 cardinal symptoms

ER or hospitalized

Question 21

AECOPD non-pharm

Answer 21

Oxygen: titrate to improve hypoxemia with target O2 saturation of 88-92%
● Non-invasive mechanical ventilation – consider for acute respiratory failure

Question 22

AECOPD Pharmacologic Treatment

3 things

Answer 22

SABD preferred, SABA may be added if symptoms perisist

Systemic corticosteroids shorten recovery time, improve lung function and arterial hypoxemia, reduce risk of early relapse
o Prednisone 40 mg daily x 5 days

Antibiotics
o Should be given to patients with
▪ 2 cardinal symptoms: increased dyspnea, increased sputum volume and
increased sputum purulence (Dipiro)
▪ Requiring mechanical ventilation

Question 23

what antibiotics should be used in this situation:

< 4 exacerbations per year
And at least 2 of the following:
- Increased sputum purulence
- Increased sputum volume
- Increased dyspnea

Answer 23

amoxicillin
doxycycline
trimethoprim/sulfamethoxazole

Treat for 5-7 days
Evidence indicates 5 days may be as effective as 7-10 days

Question 24

what antibiotics should be used in this situation:

>4 exacerbations per year and at
least 2 of the following:
- Increased sputum purulence
- Increased sputum volume
- Increased dyspnea
Or
- Failure of first line agents
Or
- Antibiotics in past 3 months

Answer 24

Amoxicillin- clavulanate
Cefuroxime
Levofloxacin

alternatives: azithromycin, clarithromycin

1. Failure of first line agents: improvement following completion of ABX therapy OR clinical deterioration after 72 hrs of ABX therapy
2. Use a different class than was used previously
3. Due to the broad spectrum of levofloxacin, potential for increasing resistance and risk of C.difficile infection, reserve this mediation for beta-lactam allergies or failure to first line agents
4. macrolides poor Haemophilus coverage and significant S. pneumoniae resistance (more anti-inflamm properties)

Question 25

end of life care

COPD patients at risk for death

Answer 25

o Very severe airflow obstruction (FEV1<30%) and hyperinflation
o Poor functional status (MRC 4-5)
o Poor nutritional status (BMI <19 kg/m2)
o Older age
o Recurrent AECOPD (esp requiring hospitalization and mech. ventilation)
o Pulmonary hypertension (PHT)
o Drugs that maybe used at end of life if no response to other therapies:
● benzodiazepines, opioids