COPD Update - Piedmont · Chronic Obstructive Pulmonary Disease (COPD) • Characterized by airflow...

Catherine Bourg Rebitch, PharmD, BCACPClinical Associate Professor

Plus “New and Improved” Products for Inhaled Therapy

COPD Update

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Disclosure

The presenter has nothing to disclose concerning possible financial or personal relationships with any entities mentioned in

this presentation.

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Learning Objectives

Summarize recommendations from clinical practice guidelines for chronic obstructive pulmonary disease (COPD)

Discuss pharmacotherapy options for COPD

Understand and demonstrate proper inhaler technique for new inhaled therapies

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Chronic Obstructive Pulmonary Disease (COPD)

• Characterized by airflow limitation that is not fully reversible

• Preventable and treatable

• Significant extrapulmonary effects contribute to severity

• Prevalence and mortality have increased over the past 20 years

Bourdet SV, Williams DM. Chronic Obstructive Pulmonary Disease. In: DiPiro JT,

Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A

Pathophysiologic Approach, 10e New York, NY: McGraw-Hill

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COPD Risk Factors




Smoking!

Environmental factors

Host factors

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COPD Symptoms

COPD National Action Plan 2017. Centers for Disease

Control and Prevention.

Constant/chronic cough

Shortness of breath

Inability to breathe

easily/take deep breaths

Excess mucus production

(coughed up as sputum)

Wheezing

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COPD Prevalence



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COPD National Action Plan



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Global Initiative for Chronic Obstructive Lung Disease (GOLD)

“Striving to improve diagnosis, prevention, and management of COPD across the globe.”

https://goldcopd.org

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Management of COPD

• Classification of airflow obstruction• Post-bronchodilator FEV1

• Assessment of symptoms• mMRC, CAT, CCQ

• Selection of pharmacotherapy• Assessment of symptoms + risk of exacerbations

Pocket Guide to COPD Diagnosis, Management, and

Prevention. A Guide for Health Care Professionals. 2019

Edition.

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Classification



Edition.

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Symptom Assessment



Edition.

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Symptom Assessment

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Pharmacotherapy Selection



Edition.

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Pharmacotherapy Selection (Initial)



Edition.

≥ 2 moderate exacerbations or ≥ 1

leading to hospitalization

0 or 1 moderate exacerbations (not leading to hospital

admission)

Group C

LAMA

Group DLAMA or

LAMA + LABA * orICS + LABA**

Group A

A Bronchodilator

Group B

A Long Acting Bronchodilator(LABA or LAMA)

mMRC 0-1 or CAT <10

mMRC ≥ 2 or CAT ≥ 10

*Consider if highly symptomatic (e.g. CAT >20)** Consider if eosinophils ≥ 300

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Management Cycle



Edition.

Adjust:• Escalate

• Switch inhaler device or molecules

• De-escalate

Review:• Symptoms (Dyspnea)

• Exacerbations

Assess:• Inhaler technique and adherence• Non-pharmacological approaches

(including pulmonary rehabilitation and self-

management education)

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Pharmacotherapy Selection (Follow-up)



Edition.

DyspneaLABA or LAMA

LABA + LAMA

• Consider switching inhaler device or

molecules• Investigate (and

treat) other causes of dyspnea

LABA + ICS

LABA + LAMA + ICS

** Consider de-escalation of ICS or switch if pneumonia, inappropriate original indication or lack or response to ICS

**

**

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Pharmacotherapy Selection (Follow-up)



Edition.

Exacerbations

LABA or LAMA

LABA + ICS

LABA + LAMA + ICS

LABA + LAMA

** Consider de-escalation of ICS or switch if pneumonia, inappropriate original indication or lack or response to ICS

**

**

RoflumilastFEV1 < 50% and

chronic bronchitis

AzithromycinIn former smokers

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Non-pharmacologic management



Edition.

Smoking Cessation

(essential!!)

Physical activity as tolerated

Flu and pneumococcal

vaccination

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Pharmacologic Options

• Bronchodilators

• Antimuscarinic drugs

• Methylxanthines (ex. theophylline- not as commonly used/overall limited evidence)

• Combination (+ inhaled corticosteroid)



Edition.

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Bronchodilators

Short acting beta agonists (SABA)• Albuterol• Levalbuterol

• Proventil® HFA, Proair® HFA, Proair RespiClick® Ventolin® HFA

• Xopenex®

Long acting beta agonists (LABA)• Salmeterol• Formoterol• Olodaterol• Indacaterol

• Serevent Diskus®• Formoterol Aerolizer®• Striverdi Respimat®• Arcapta Neohaler®




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Antimuscarinic drugs




Short acting antimuscarinic (SAMA)• Ipratropium • Atrovent® MDI

Long acting antimuscarinic (LAMA)• Tiotropium• Aclidinium• Umeclidinium• Glycopyrrolate

• Spiriva Handihaler®, Spiriva Respimat®• Tudorza Pressair® • Incruse Ellipta®• Seebri Neohaler®

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Combinations




SABA/SAMA• Albuterol + Ipratropium • Combivent Respimat®

LABA/Inhaled corticosteroid [ICS]• Salmeterol + fluticasone• Formoterol + budesonide• Vilanterol + fluticasone

• Advair MDI®, Advair Diskus®• Symbicort MDI®• Breo Ellipta®

LABA/LAMA• Indacaterol + glycopyrrolate• Vilanterol + umeclidinium• Olodaterol + tiotropium• Formoterol + glycopyrrolate

• Utibron Neohaler®• Anoro Ellipta®• Stiolto Respimat®• Bevespi Aerosphere® MDI

LABA/LAMA/ICS• Vilanterol + umeclidinium +

fluticasone

• Trelegy Ellipta®

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Inhaler Misuse = Big Problems!

• Observational study (n = 1664 adults) evaluating proper inhaler technique

• Out of 2288 records, critical mistakes in technique noted in 12% MDI, 35% Diskus and HandiHaler, and 44% Turbuhaler users

• Inhaler misuse associated with:• Older age, lower schooling, and lack of instruction by a healthcare

professional

• Increased risk of hospitalization, ER visits, courses of oral steroids and antibiotics, and poor disease control based on symptom questionnaires

Melani AS, Bonavia M, Cilenti V et al. Inhaler mishandling

remains common in real life and is associated with reduced

disease control. Respiratory Medicine (2011): 105, 930-38.

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New Inhaler Devices: Respimat®

Spiriva Respimat Package Insert. Copyright 2018

[revised May 2018] Boehringer Ingelheim

International GmbH.

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International GmbH.

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International GmbH.

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International GmbH.

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International GmbH.

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New Inhaler Devices: Ellipta®

Breo Ellipta Package Insert. Copyright 2017

[revised December 2017] GlaxoSmithKline.

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New Inhaler Devices: Pressair®

Tudorza Pressair Package Insert. Copyright 2017

[revised June 2017] AstraZeneca.

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New Inhaler Devices: Neohaler®

Utibron Neohaler Package Insert. Copyright 2017

[revised May 2017] Sunovion Pharmaceuticals Inc.

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Show and Tell

I will be seated at a table during lunch (now!) with lots of inhaler demos for you to peruse.

Please stop by!

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Summary

• COPD is chronic, progressive, and causes significant morbidity and mortality.

• Inhaled therapy is a cornerstone of management, and inhaler technique plays a pivotal role in disease state control.

• New inhaler devices aim to improve adherence and outcomes through updated drug delivery systems.

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Learning Objectives

Summarize recommendations from clinical practice guidelines for chronic obstructive pulmonary disease (COPD)

Discuss pharmacotherapy options for COPD

Understand and demonstrate proper inhaler technique for new inhaled therapies

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Questions/Comments?

COPD Update - Piedmont · Chronic Obstructive Pulmonary Disease (COPD) • Characterized by airflow...

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Transcript of COPD Update - Piedmont · Chronic Obstructive Pulmonary Disease (COPD) • Characterized by airflow...