COPD

NEW DRUGS, NEW DEVICES AND CONSIDERATIONS FOR BEST PRACTICE

September 2015

INSIDE

Pg 2: COPD Overview - a birds eye view

Pg 3: COPD Pharmacotherapy Comparison Chart

- sorting out all the medication options

Pg 4: Asthma & COPD Inhalation Devices Chart assessing the pros & cons

when individualizing inhaler choice

Pg 5: COPD Inhaler Technique - an illustrated guide

Pg 6-12: Geri-RxFiles COPD - a review of the treatment

of COPD as it relates to older adults (excerpted from upcoming 2nd Edition)

RESOURCES & LINKS

(may follow links via the PDF posted online at www.RxFiles.ca)

Canadian 2007 guidelines Canadian 2008 guidelines for

family physicians GOLD 2015 guidelines CHEST 2015 guidelines for

prevention of AECOPD Pulmonary rehab programs in

Saskatchewan COPD action plan templates Link to SK Lung Association for

a) Inhaler Education Videos b) COPD Educator List

COMING THIS NOVEMBER

Geri-RxFiles

2nd Edition

There are lots of developments on the landscape of chronic obstructive

pulmonary disease (COPD) management. This RxFiles release contains a variety of information that we hope will assist you in navigating new treatment options and looking for ways to optimize clinical endpoints.

DISCLAIMER: The content of this newsletter represents the research, experience and opinions of the authors and not those of the Board or Administration of Saskatoon Health Region (SHR). Neither the authors nor Saskatoon Health Region nor any other party who has been involved in the preparation or publication of this work warrants or represents that the information contained herein is accurate or complete, and they are not responsible for any errors or omissions or for the result obtained from the use of such information. Any use of the newsletter will imply acknowledgment of this disclaimer and release any responsibility of SHR, its employees, servants or agents. Readers are encouraged to confirm the information contained herein with other sources. Additional information and references online at www.RxFiles.ca Copyright 2015 RxFiles, Saskatoon Health Region (SHR)

Highlights for COPD Management

1) Encourage smoking cessation 2) Ensure patient has the recommended

vaccinations (influenza & pneumococcal) 3) Refer for pulmonary rehabilitation

whenever possible, especially after a recent exacerbation

4) Assess for proper inhaler technique and/or refer to a pharmacist or a respiratory educator

5) Choose a device that is best suited for the patient

6) Consider the role of an action plan 7) Reserve inhaled corticosteroids for those

who present with frequent exacerbations or poor control with LAMA + LABA

In one recent study, 59% of patients misused

their inhaler devices!1

Above: Zack is just being silly!

1. Batterink J, Dahri K, Aulakh A, Rempel C. Evaluation of the use of inhaled medications by hospital inpatients with chronic obstructive pulmonary disease. Can J Hosp Pharm. 2012 Mar;65(2):111-8.

Page 1

http://www.rxfiles.ca/http://www.respiratoryguidelines.ca/sites/all/files/CTS_COPD_Guidelines_2007_Update.pdfhttp://www.respiratoryguidelines.ca/sites/all/files/CTS_COPD_Highlights_2008.pdfhttp://www.respiratoryguidelines.ca/sites/all/files/CTS_COPD_Highlights_2008.pdfhttp://www.goldcopd.org/uploads/users/files/GOLD_Report_2015.pdfhttp://journal.publications.chestnet.org/data/Journals/CHEST/933666/chest_147_4_894.pdfhttp://journal.publications.chestnet.org/data/Journals/CHEST/933666/chest_147_4_894.pdfhttps://sk.lung.ca/sites/default/files/documents/2015/2015%20SK%20Pulmonary%20Rehab%20List.pdfhttps://sk.lung.ca/sites/default/files/documents/2015/2015%20SK%20Pulmonary%20Rehab%20List.pdfhttp://www.respiratoryguidelines.ca/updated-cts-copd-action-planhttps://sk.lung.ca/services/find-asthma-or-copd-educatorhttps://sk.lung.ca/health-professionals/certified-educators-saskatchewanhttp://www.rxfiles.ca/

COPDOverview ACrawley,BSP www.RxFiles.ca Sept2015Whatisit?

Progressive,partiallyreversibleairwaylimitation Damagetothewallsofthelungsreducedelasticityreducedabilityofpatienttoexhale

4thleadingcauseofdeathinCanada;prevalence~5% Primarycause(85%ofcases)issmoking Anestimated1520%ofsmokersdevelopCOPD

Symptoms:Cardinaltriad:dyspnea,chroniccough,andsputumproduction.Dyspneaistypicallyprogressive,worsenswithexercise,persistent;describedasgasping.Definitions:Emphysemadescribesthedamagetothelungs.Chronicbronchitisisdefinedasincreasedcoughandsputum.MostCOPDpatientshavefeaturesofboth.Diagnosis:SpirometrypostbronchodilatorFEV1/FVC

COPD:DrugComparisonChart1,2,3,4,5,6,7,8 ACrawleyBSP,BJensenBSP,LRegierBSP www.RxFiles.ca Sept2015 GENERIC/TRADE

(Strength&formulations) USUALDOSE[MAXDAILYDOSE]COMMENTS/ADVERSEEVENTAE/CONTRAINDICATIONSCI/

DRUGINTERACTIONSDI/MONITORINGM

$/30dayShortActingMuscarinicAntagonist(SAMA):bindsunselectivelytopulmonarymuscarinicreceptors,reducingsmoothmusclecontraction.Duration46hours.1stlineinmildCOPD.IpratropiumATROVENT20mcgMDI;250,500mcg/2mLnebs;inhalationsoln(fordilution)

HFA:40mcg(2puffs)inhaledTIDQID[16puffs/day]Neb:500mcg(1neb)inhaledTIDQID[2000mcg]

ImprovesCOPDsymptoms;doesnotreduceexacerbations.Onset

ASTHMAANDCOPD:INHALATIONDEVICESCHART ACrawleyBSP,LRegierBSP,BJensenBSPwww.RxFiles.ca Sept2015Thereisnoevidencetosuggestonedeviceworksbetterthananother.Poorinhalertechnique:efficacy.Ptdevicedissatisfaction:adherence.Choosedevicebasedonpros/consbelow&patientpreference.

beclomethasoneQVARciclesonideALVESCOfluticasoneFLOVENTformoterol/mometasone

ZENHALEsalmeterol/fluticasoneADVAIRipratropiumATROVENTsalbutamolVENTOLIN

olodaterolSTRIVERDIsalbutamol/ipratropiumCOMBIVENTtiotropiumSPIRIVAtiotropium/olodaterolINSPIOLTO

HandiHaler:tiotropiumSPIRIVABreezhaler:glycopyrroniumSEEBRIglycopyrronium/indacaterolULTIBROindacaterolONBREZ

formoterolOXEZEformoterol/budesonide

SYMBICORTterbutalineBRICANYL

salbutamolVENTOLINsalmeterolSEREVENTsalmeterol/fluticasoneADVAIR

aclidiniumTUDORZAaclidinium/formoterolDUAKLIR

umeclidiniumINCRUSEvilanterol/fluticasoneBREOvilanterol/umeclidinium

ANOROfluticasonefuroateARNUITY

DEVICE MDI Respimat HandiHaler,Breezhaler Turbuhaler Diskus Genuair Ellipta

DescriptionDeliversaerosolizedstreamofmedicationover~0.2seconds.

Usesaspringtodelivera"softmist"ofmedicationover~1.5

seconds.

Capsulescontainingmedicationarepierced,

thenpowderinsideisinhaled.

Drypowderinhalercontainingareservoirof

medication.Drypowderinhalercontainingsingledoseblistersofmedication.

Lowinspiratoryflow20L/minrequired Breathactuated:reducesneedforhandbreathcoordination Fewsteps,easytouse(comparedtoHandiHalerorBreezhaler).

Pros

Suitableforallages.Note:spacerstronglyrecommendedregardlessofage(seecommentsbelow).

Spacerwithamaskavailableforcognitiveimpairment,frail,

COPD Inhaler Technique A Crawley BSP www.RxFiles.ca Sept 2015 Inhaler Device Step 1: PREPARE DOSE

Step 2: BREATHE

OUT

Step 3: BREATHE

MEDICATION IN

Step 4: HOLD BREATH x10 SECSStep 5: BREATHE

OUT

Comments

AERO

SOLI

ZED Metered Dose Inhaler (MDI)

Ipratropium ATROVENT

Salbutamol VENTOLIN

Formoterol/mometasone ZENHALE Salmeterol/fluticasone ADVAIR

- Shake inhaler gently. - Remove cap (cap prevents foreign

objects from entering device when not in use).

Prime inhaler (x 4 sprays) if not used for 5 days.

Visible mist from the top of inhaler or sides of mouth an indicator of mistimed breath.

Adding spacer reduces need for hand-breath coordination.

Common error: breathing too fast

SOFT

MIS

T Respimat Tiotropium SPIRIVA Olodaterol STRIVERDI Salbutamol/ipratropium

COMBIVENT Tiotropium/olodaterol INSPIOLTO

- Turn the clear base turn (counter-clockwise). Remove cap.

Prime inhaler (until mist is visible, then 3 more sprays) if first time use OR if not used for 21 days. Prime inhaler (x 1 spray) if not used for 3 days (COMBIVENT) or 7 days SPIRIVA/INSPIOLTO).

- Place lips over mouthpiece - Time the release of the dose just after

the start of the inhalation - Take a slow, deep inhalation (5 seconds)

Do not cover air vent with fingers or mouth during inhalation.

Requires prior setup to load canister into base.

After loading, canister expires in 3 months.

HandiHaler Tiotropium SPIRIVA

- Open device and insert one capsule. Close mouthpiece portion.

- Pierce capsule by pressing the side button, pressing once only.

After inhalation, open to see empty capsule; discard it.

Keep capsules in foil packaging until immediately before use.

Rattling capsule heard if dose inhaled correctly.

Breezhaler Glycopyrronium SEEBRI Glycopyrronium/indacaterol ULTIBRO Indacaterol ONBREZ

- Remove cap. - Open device and

insert one capsule. Close mouthpiece.

- Pierce capsule by pressing the side buttons, pressing once only.

After inhalation, open to see empty capsule; discard it.

Keep capsules in foil packaging until immediately before use.

"Whirring" noise heard if dose inhaled correctly.

May leave sweet after-taste.

Turbuhaler Formoterol OXEZE Formoterol/budesonide SYMBICORT Terbutaline

BRICANYL

- Remove cap. - Keep device upright. - Twist base counter-clockwise

as far as it will go. - Twist base clockwise until

"click" is heard.

Doses will not be lost even if base is twisted multiple times; however, dose counter will no longer be accurate.

"Red" dose indicator signals approximately 20 doses remaining.

Diskus Salbutamol VENTOLIN Salmeterol SEREVENT Salmeterol/fluticasone ADVAIR

- Slide cover open. - Push dose-release

lever until "click" is heard.

Hold Diskus level & horizontal to ensure dose is not lost.

Genuair / USA: Pressair Aclidinium TUDORZA Aclidinium/formoterol DUAKLIR

- Remove cap. - Press and release top

button; control window changes from red to green.

Control window changes from green to red if dose inhaled correctly.

"Click" heard if dose inhaled correctly.

When no doses remain, green button remains depressed ("locked").

DRY

POW

DER

INH

ALER

S (b

reat

h ac

tuat

ed)

Ellipta Umeclidinium INCRUSE Vilanterol/fluticasone BREO Vilanterol/umeclidinium ANORO

Fluticasone furoate ARNUITY (for asthma)

- Flip over cover until "click" is heard.

For dry powder inhalers

(HandiHaler; Breezhaler; Turbuhaler;

Diskus; Genuair; Ellipta),

breathe AWAY from the device

to avoid disturbing the powder. Avoid

tipping the device.

- Place lips over mouthpiece - Take a forceful, deep inhalation

May take second breath from dry powder devices to ensure entire dose inhaled. For HandiHaler and Breezhaler, take a second

breath if capsule still contains powder.

Step 4

- Hold medication in the

lungs for 10 seconds. If unable to achieve 10 seconds, hold breath for as long as comfortable

Step 5

Exhale. Do not exhale into the device.

If using a corticosteroid inhaler, rinse mouth (gargle

and spit) as final step to prevent thrush, dysphonia, etc. May also rinse mouth

when using an anticholinergic (e.g. LAMA) inhaler - this can decrease

the incidence of dry mouth.

Ideal to wait ~1 minute between inhalations of the

same medication and ~5 minutes between different

medications.

Do not cover air vent with fingers during inhalation.

Dose is lost if Ellipta is opened and closed without inhaling the dose.

Expires 6 weeks after removal from protective packaging.

Press top of MDI to release dose

Press Respimatbutton to release dose

"Inhale as hard as you can, for as long as you can."

=EDS =Non Forumulary Sask =prior approval NIHB =not covered by NIHB MDI=metered dose inhaler Page 5

http://www.rxfiles.ca/

COPDinOlderAdults1,2,3,4 www.rxfiles.ca

Chronicobstructivepulmonarydisease(COPD)ismostcommonlytheresultofprogressiveexposuretocigarettesmokeandotherlungirritants.Lungdamagetakestimetomanifest;thus,theprevalenceofdiseaseincreaseswithage.Symptomsincludeshortnessofbreath(dyspnea),chroniccough,andsputum(phlegm)production.PeoplewithCOPDoftenhavedifficultyexhalingtheirdamagedlungshavelostelasticity,andnolongercancontractproperly.Theresultisairflowlimitation.

Airflowlimitationcanbemeasuredthroughspirometry,andthisishowCOPDisdiagnosed.AnindividualhasCOPDif,aftertakingabronchodilator,thevolumeofairexhaledin1second(FEV1)islessthan70%ofthetotalamountofairthatleavesthelungswithfullexhalation(FVC).(AnotherwayofsayingthisisthatFEV1/FVC65years.(Arepeatdoseafter5to10yearsinhighriskindividualsmaybegiven;however,thisseconddoseisnotcoveredinSK,~$65).

o AmericanAdvisoryCommitteeonImmunizationPracticesrecommendsadministeringbothPneuC13PREVNAR13andPneuP23PNEUMOVAX23inseriestoalladults65years.CanadianNationalAdvisoryCommitteeonImmunization,however,onlyrecommendsadministeringbothinseriestoadultswithimmunocompromisingconditions(e.g.solidorganorstemcelltransplant,congenitalimmunodeficiencies,asplenia).

SelecttheinhaledpharmacotherapybestsuitedfortheindividualTherecentadditiontothemarketofnewinhalersanddosageformshascreatedadiversityofchoices,allowingtherapytobeselectedbasedonindividualizedfactors.Healthcareprovidersmusthaveanunderstandingoftherelativeadvantagesanddisadvantagesofeachagent.MedicationsApprovedforCOPD

Table1.Shortactingbetaagonists(SABAs)andshortactingmuscarinicantagonists(SAMAs)Medication AvailableIn UsualDose

SalbutamolVENTOLINMetereddoseinhaler100mcgDiskus200mcgNebules1.25,2.5,5mg/2.5mL

12puffsinhaledQIDprn1puffinhaledQIDprn2.5mginhaledQIDprnSABA

TerbutalineBRICANYL Turbuhaler500mcg 1puffinhaledQIDprn

SAMA IpratropiumATROVENT Metereddoseinhaler20mcgNebules250,500mcg/2mL2puffsinhaledQIDprn500mcginhaledQIDprn

SABA+SAMA

Salbutamol+IpratropiumCOMBIVENT

Nebules2.5/0.5mgper2.5mLRespimat20/100mcg

1nebinhaledQIDprn1puffinhaledQIDprn

Table2.Longactingmuscarinicantagonists(LAMAs)*

Medication AvailableIn DoseTiotropiumSPIRIVAUPLIFTTrial

HandiHaler18mcgcapsuleRespimat2.5mcg

1capinhaledoncedaily2puffsinhaledoncedaily

AclidiniumTUDORZA Genuair400mcg 1puffinhaledBIDGlycopyrroniumSEEBRI Breezhaler50mcgcapsule 1capinhaledoncedailyUmeclidiniumINCRUSE Ellipta62.5mcg 1puffinhaledoncedaily

*somereferencesrefertoLAMAsasLAACs(longactinganticholinergics)

Table3.Longactingbetaagonists(LABAs)Medication AvailableIn Dose

SalmeterolSEREVENT Diskus50mcg 1puffinhaledBID

FormoterolFORADIL,OXEZE Aerolizer12mcgcapsuleTurbuhaler6,12mcg1capinhaledBID6to12mcginhaledBID

IndacaterolONBREZ Breezhaler75mcgcapsule 1capinhaledoncedailyOlodaterolSTRIVERDI Respimat2.5mcg 2puffsinhaledoncedaily

Table4.CombinationLAMAandLABA

Medication AvailableIn DoseUmeclidinium+VilanterolANORO Ellipta62.5/25mcg 1puffinhaledoncedailyGlycopyrronium+IndacaterolULTIBRO Breezhaler50/110mcg 1puffinhaledoncedailyTiotropium+OlodaterolINSPIOLTO Respimat2.5/2.5mcg 2puffsinhaledoncedailyAclidinium+FormoterolDUAKLIR Genuair340/12mcg 1puffinhaledBID

Figure1.EffectsofSmokingandStoppingSmokingonFEV1.

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COPDinOlderAdultscontinued www.rxfiles.ca

Table5.CombinationLABAandInhaledcorticosteroids(ICS)*Medication AvailableIn Dose

Formoterol+BudesonideSYMBICORTTurbuhaler6/100,6/200mcg 12/400mcginhaledBIDSalmeterol+FluticasoneADVAIR

TORCHTrialDiskus50/100,50/250,50/500mcg 50/250mcginhaledBID

Vilanterol+FluticasoneBREO

SUMMITTrial Ellipta25/100mcg 1puffinhaledoncedaily

*Alsoavailable:Formoterol+MometasoneZENHALE,butnotofficiallyindicatedforCOPD&Salmeterol+FluticasoneADVAIRHFA,notofficiallyindicatedforCOPDADVAIRDISKUSisindicated

ConsiderationsforSelectionofPharmacotherapy RelatingtherapytostageofCOPD.Initialtherapymaybebasedonseverityof

disease.Bothsymptomsandspirometryshouldbeassessedtoachievethemostaccuratestaging.10

Table6.StagingofCOPDbasedonsymptomsandspirometryCOPDStage *MRC mMRC Symptom/Disability FEV1

AtRisk 1 0 Ionlygetbreathlesswithstrenuousexercise.Mild 2 1 Igetshortofbreathwhenhurryingonthelevelorwalkingupaslighthill.

>80%

3 2Onlevelground,Iwalkslowerthanpeopleofthesameagebecauseofbreathlessness,orIhavetostopforbreathwhenwalkingatmyownpaceonthelevel.Moderate

4 3Istopforbreathafterwalkingabout100meters(~1streetblock)orafterafewminutesonlevelground.

5080%

Severe 3050%VerySevere

5 4 IamtoobreathlesstoleavethehouseorIambreathlesswhendressing.

COPDinOlderAdultscontinued www.rxfiles.ca

Decidingbetweenmedicationsinthesameclass.OncethedecisionhasbeenmadetochooseLAMAorLABAtherapy,thenextstepistopickwhichLAMA(orLABA).Thefollowingpointscaninformthedecision.

a) EvidenceThemoststudied(i.e.,oldest)COPDagentsaretheLAMAtiotropiumandtheLABAssalmeterolandformoterol;thesemedicationshavethemostevidencesupportingtheiruse.

b) Availabledevices Somepeoplewillhaveapreferenceforwhichinhalationdevicetheyuse.Thisisbecausesomedevicesareeasiertousethanothers,especiallyforpeoplewitharthritichandsorcognitiveimpairment.SeeRxFilesAsthma&COPD:InhalationDevicesforafullcomparison.Considerusingthesametypeofdeviceforeachmedication.

c) AdherenceOncedailyregimens(forLAMAs:tiotropium,glycopyrronium,umeclidinium;forLABAs:indacaterol,olodaterol)mayofferanadherenceadvantageovertwicedailyregimens.

d) OnsetFormoterol,indacaterol,olodaterol,andvilanterol(LABAs),andglycopyrronium(LAMA)workwithinminutes.Theotheragentstakelonger(anhourormore)tostarthavinganeffect.Fastactingagentsmaygiveindividualsmoreconfidenceinthemedication'sefficacy.

WhentoaddanICS?InhaledsteroidsshouldnotbeusedasmonotherapyinCOPDthisisassociatedwithincreasedmortality(NNH=29overthreeyearsvscombinationtherapywithLABA).TORCHICSshaveevidenceforreducingexacerbationsinCOPD(aLABA/ICScomboreducesexacerbationsbythesameamountasaLAMA),butevidenceisinconsistentregardingsymptomimprovement.19ICSsalsohavesideeffects(e.g.thrush5%,hoarseness5%,increasedriskofpneumoniaNNH=16overthreeyears).20,21,22,23ThusthebestuseofICSsmaybeinindividualswithfrequentexacerbations(1ormoreperyear),orwithseveresymptomsunresponsivetoothertreatments.

TORCHTrialMedications(intervention)

Salmeterol+FluticasoneADVAIR50/500mcgORfluticasone500mcgORsalmeterol50mcgORplaceboallBID

StudyDesign3yearmulticentre,randomised,doubleblind,parallelgroup,placebocontrolled

TrialPopulation ModeratetosevereCOPDwithatleasta10packyearsmokinghistory

1EndPoint Allcausemortalityat3years

Results

Probabilityofdeath:salmeterol+fluticasone12.6%,salmeterol13.5%,fluticasone16.0%,placebo15.2%.Thesefindingswerenonsignificant.Exacerbationrate:Salmeterol+Fluticasone0.85/year,Salmeterol0.96/year,fluticasone0.93/year,placebo1.13/year.Thesefindingswerenonsignificant.

SUMMITTrial:fluticasonefuroate/vilanterol(100/25g)BREOORfluticasonefuroate(100g)ORvilanterol(25g)ORplacebowithmortalityastheprimaryendpoint.Preliminaryfindingsarealsononsignificantfortheprimaryendpoint.

Refertopulmonaryrehabilitation

Pulmonaryrehabreducesdyspnea(shortnessofbreath),andimprovesexercisetoleranceandqualityoflife.ItmayalsoreducetheanxietyanddepressionassociatedwithCOPD.24

Pulmonaryrehabisstandardofcareforindividualswithuncontrolledsymptomsdespiteoptimizedbronchodilators.25Aswell,inindividualswitharecent(30daysagoorless)acuteexacerbationofCOPD,25weeksofpulmonaryrehabresultedinasignificantreductioninhospitalizations(NNT=4topreventonehospitalization).26

Visitwww.lung.ca/lunghealth/gethelpforalistofpulmonaryrehabprogramsacross

Canada.IndividualswithCOPDRequireLongTermFollowUp CreateanindividualizedCOPDactionplanwiththeindividual

Visitwww.respiratoryguidelines.ca/updatedctscopdactionplanfortemplatestocreateaCOPDactionplan.

Monitoradherenceandensureappropriateinhalertechnique

About50%ofindividualswithCOPDarenonadherent,andabout50%cannotdemonstrateappropriateinhalertechnique.27,28,29Reevaluateinhalertechniqueregularly.

ConsiderreferralforteachingbyapharmacistorcertifiedCOPDeducator. SeeGeriRxFiles:COPDInhalerTechniqueonpage128

ForindividualswithsevereCOPD,supplementaloxygenmaybeconsidered

Inhypoxic(lowbloodoxygensaturation)individuals,15hoursperdayormoreofoxygenisassociatedwithimprovedsurvivalandqualityoflife.30FundingisavailableinSaskatchewanforhomeoxygen.31Thetargetisanoximetrysaturationof90%to92%.

Forindividualswithseverediseaseprogression,refertoarespiratoryspecialist

Referralmaybeappropriatewhen:a) thereisuncertaintyinthemanagementordiagnosis;b) symptomsaredisproportionatetothelevelofairflowobstruction;c) thedeclineinpulmonaryfunctionisaccelerated;d) exacerbationsofCOPDaresevereorrecurrentorcausehospitalization;e) thereisaninadequateresponsetotherapy;orf) theindividualentersrespiratoryfailure.32

Specialistsmayconsiderstartingoxygentherapy,theophylline,roflumilast,prophylacticazithromycin,ornacetylcysteine.

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COPDinOlderAdultscontinued www.rxfiles.ca

AcuteExacerbationsofCOPD(AECOPD)COPDexacerbationsareasustainedworsening(>48hours)ofrespiratorysymptoms.Exacerbationsbecomemorefrequentasdiseaseseverityprogresses.

OlderadultsareoftenslowtorecoverfromCOPDexacerbations.Itmaytakeweeks(ormore)toreturntobaseline.Greateffortsshouldbemadetopreventexacerbationsbecauseexacerbationscanacceleratethedeclineinlungfunctionandhavesignificantmortalityrisk. PreventacuteexacerbationsofCOPDThereareseveralevidencebasedinterventionstopreventacuteexacerbationsofCOPD:33

1. Optimizationandadherencetoprescribedpharmacotherapy2. Vaccinations(i.e.influenza,pneumococcal)3. Avoidenvironmentaltriggers(e.g.dust,pollutants)4. Smokingcessation5. Pulmonaryrehabilitation

TreatacuteexacerbationsofCOPD Treatmentconsistsofshortactingbronchodilators,oralcorticosteroids,and

antibioticswhenindicated.

AECOPDBronchodilatorTherapyInitiateinhaledSAMAandSABAtherapyscheduledevery4to6hours(e.g.salbutamol100mcgMDI1to2puffsQIDwithipratropium20mcgMDI1to2puffsQID).TemporaryuseofhigherdosesofSAMA/SABAtherapyisoftenusedinseverecases/hospitalizedindividuals.ThereisclinicalcontroversyonwhetheraSAMA/SABAcombinationismoreeffectivethanasingleagent;thecombinationisoftenuseddespitealackofevidence.34

BronchodilatortherapymaybeadministeredviaMDIandspacer;nebulizedtherapycanbevaluableifanindividualisunabletouseproperinhalertechnique.

Longactinginhalersmaybecontinued(iftheindividualisabletotake),butshouldnotbeusedasasubstituteforshortactingbronchodilators.

AECOPDCorticosteroidTherapy Initiateoralprednisone30to50mgfor5to14days.REDUCETrial:5daytreatment

ofprednisone40mgwasnoninferiorto14daytreatmentwithregardtoreexacerbationwithin6monthsoffollowup,butsignificantlycorticosteroidexposure.Thesefindingssupporttheuseofa5daycorticosteroidtreatmentinAECOPD.35Choosealowerdoseinindividualswhoarefrailorhavealowbodyweight.Taperingisnotusuallyrequiredfortheseshortcoursesofcorticosteroids,unlesstheindividualhasreceivedfrequentcourses(expertopinion:4)overthepastyear.

Considermatchingthedurationofsteroidtherapywiththedurationofantibiotictherapy(ifanantibioticisindicated).Monitorforcorticosteroidsideeffects,e.g.hyperglycemia,nausea,insomnia.

AECOPDAntibioticTherapyApproximatelyhalfofCOPDexacerbationshaveaninfectiouscause.Anassessmentofsymptoms(sputumpurulence,sputumvolume,anddyspnea)canpredictthelikelihoodofabacterialetiology.

EvaluateprobableetiologyofCOPDexacerbation Ideally,twocriteriashouldbemetbeforeinitiatingantibiotics:36

Table7.AECOPDantibioticchoiceandoraldosing

Lowriskindividuals

amoxicillin 500mgTIDfor7to10days CrCl1030mL/min500mgBIDdoxycycline100mgBIDfor7to10daysTMP/SMX800/160mgBIDfor7to10days CrCl1530mL/min400/80mgBIDclarithromycin 500mgBIDfor5to10days CrCl

COPDinOlderAdultscontinued www.rxfiles.ca

ConsiderationsforCOPDEndofLifeManagementAsCOPDprogresses,individualstypicallyexperienceagradualdeclineinfunction&ability.Exacerbationsmaybecomemorefrequent,andaftereachexacerbationafullreturntobaselinefunctionmaynotbepossible.

AnindividualwithsevereCOPD(FEV1lessthan50%)hasa40%chanceofmortalityover4years,andasFEV1deterioratestheriskofdeathrises.

38OnevalidatedwaytopredictthelikelihoodofmortalityinsomeonewithCOPDistouseadditionalfactorsbeyondFEV1,suchasexercisecapacity,amountofdyspnea,andBodyMassIndex.ThisissummarizedinatoolcalledtheBodeIndex,andacalculatorcanbefoundhere:http://www.qxmd.com/calculateonline/respirology/bodeindex ForCOPDpatientswithahighriskofdeathinthenearfuture,initiateanendoflife

carediscussion

Discussionsaboutendoflifecareoftenoccurtoolate.Asaresult,individualsmaybetoosicktoproperlymakecaredecisions.

Thebesttimeandplacetoplanforendoflifecareiswithascheduledappointmentinaphysiciansoffice.Participantsshouldincludetheindividual,thephysician,andthefamilymember(s)whomaybemakingfuturedecisionsfortheindividual.

ConsiderationsforCOPDEndofLifeManagementcontinued

ForCOPDpatientswithahighriskofdeathinthenearfuture,initiateanendoflifecarediscussioncontinued

Ingeneral,endoflifecarediscussionsshouldincludethefollowing:39a) Adecisiononthelocationandproviderofterminalcare.b) Theroleoffamilymembersinmakingfuturedecisions.c) Documentationofthedesiretouseorwithholdmechanicalventilation.d) Reassurancethatsymptomswillbemanagedanddignitypreserved.

Forpearlsonhowtoinitiateandframeanendoflifediscussion,refertopage40oftheAlosaFoundation'sCOPDhighlightsathttp://www.alosafoundation.org/wpcontent/uploads/2013/12/COPDSmokingCessationEvidenceDocument.pdf

ManagethesymptomsofendstageCOPD InpeoplewithendstageCOPD,twocommonsymptomstoaddressarepersistentdyspnea

anditsaccompanyinganxiety.1Firstensurethatbronchodilatortherapyisoptimized(seeFigure2).Next,opioidscanbeusedtoreducethesensationofdyspnea(e.g.morphine2.5to5mgorallyinolderadultsevery4hoursifneeded).40Opioidtolerantindividualsmayrequireanincreaseintheircurrentdose(e.g.increaseby2550%).Thereisnoevidencethatnebulizedopioidsarebetterthanoralorsubcutaneous.Benzodiazepinecanbeaddedtoopioidtherapyformanagementofanxiety(e.g.lorazepam12mgorallyeveryhouruntilrelaxed,thenevery4hoursasneeded).SeeRxFilesPalliativeCare.

Nonpharmacologicalapproachestomanagedyspneaincludesittingtheindividualupright,removingsmokeandotherirritants(e.g.perfume),ensuringfreshairwithsufficienthumidityissupplied,andminimizingotherfactorsthatcanincreaseanxiety.41

REMEMBERTOALWAYSREASSESSINHALERTECHNIQUE,WHENEVERPOSSIBLE.Itisnotuncommontofindthosewhothinktheyareusingcorrectlyandeverythingisoktillyouaskthemtodemonstrate.

{Someofourteamhadabittoomuchfunwhenaskedtodemonstrateanincorrecttechnique!}

Hope for the best. Prepare for the worst.

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COPD:STOPP&BeersCriteria Formoredetailedmedicationinformation,seetheRxFilesDrugComparisonCharts

DrugorDrugClassSTOPP

Beers

RxFilesWhenaMedicationCouldbeProblematicforOlderAdults14 ClinicalConcern

14

QE=QualityofEvidenceSR=StrengthofRecommendation

S WithahistoryofNARROWANGLEGLAUCOMA

MayexacerbateglaucomaAntiMuscarinicBronchodilatorsIpratropiumATROVENTTiopropiumSPIRIVA

S WithBLADDEROUTFLOWOBSTRUCTION Maycauseurinaryretention

Benzodiazepines

Short&IntermediateActing:AlprazolamXANAX t1/2 ~ 12 hours Bromazepam LECTOPAM t1/2 ~ 20 hours Lorazepam ATIVAN t1/2 ~ 15 hours Oxazepam SERAX t1/2 ~ 8 hours Temazepam RESTORIL t1/2 ~ 11 hours Triazolam HALCION t1/2 ~ 2 hours

LongActing:Chlordiazepoxide LIBRIUM t1/2 ~ 100 hoursClonazepam RIVOTRIL t1/2 ~ 34 hours Clorazepate TRANXENE t1/2 ~ 100 hours Diazepam VALIUM t1/2 ~ 100+ hours Flurazepam DALMANE t1/2 ~ 100+ hours Nitrazepam MOGADON t1/2 ~ 30 hours

SWithACUTEORCHRONICRESPIRATORYFAILURE(i.e.pO26.5kPa)

Riskofexacerbationofrespiratoryfailure

Corticosteroids,Systemic

BudesonideENTOCORTDexamethasoneDECADRONHydrocortisoneCORTEFMethylprednisoloneMEDROLPrednisolonePrednisone

S

ForMAINTENANCETHERAPYINMODERATETOSEVERECOPD(insteadofinhaledcorticosteroids)

*AcuteExacerbationsCOPD(AECOPD)oralorparenteralcorticosteroids(dosagesof30to50mgofprednisoneequivalentperdayfor5days)arerecommendedandareappropriateinmostpatientswithmoderatetosevereAECOPD42.

Unnecessaryexposuretolongtermsideeffectsofsystemiccorticosteroids(willbedependentupondose&durationoftreatment):Fluid/electrolyteimbalance,pituitaryadrenalsuppression,hypertension,cutaneouseffects(dermalthinning,easybruising,&acne),hyperglycemia,glycosuria,pepticulcer,behaviouraldisturbances(insomnia,euphoria),posteriorsubcapsularcataracts,glaucoma,bonemineraldensity,cushingoidsyndrome,avascularnecrosisofboneincludinghip(rare).

S MonotherapyforCOPD Safer,moreeffectivemedicationsavailable

Riskofadverseeffectsduetonarrowtherapeutic

index

Xanthine,OralBronchodilatorTheophyllineTHEOLAIR,UNIPHYL

BWithINSOMNIAQE=Moderate;SR=Strong

CNSstimulation

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GERI-RXFILES COPD REFERENCES

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25 Criner GJ, Bourbeau J, Diekemper RL,et al. Executive Summary: Prevention of Acute Exacerbation of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. Chest. 2015 Apr 1;147(4):883-93. 26 Puhan, Milo A., et al. "Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease." Cochrane Database Syst Rev 2011;10:10. 27 Bourbeau, J., and S. J. Bartlett. Patient adherence in COPD. Thorax 2008;63(9): 831-838. 28 Molimard, Mathieu. How to achieve good compliance and adherence with inhalation therapy. Current Medical Research and Opinion 2005;21:S33-S37. 29 Molimard, M., Raherison, C., Lignot, S., Depont, F., Abouelfath, A., & Moore, N. Assessment of handling of inhaler devices in real life: an observational study in 3811 patients in primary care. Journal of aerosol medicine, 2003;16(3):249-254. 30 O'Donnell DE, Aaron S, Bourbeau J, Hernandez P, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease 2007 update. Can Respir J. 2007 Sep;14 Suppl B:5B-32B. 31 SAIL Oxygen Testers Handbook 2012 edition available at https://sk.lung.ca/testers/study/Tester_Handbook.pdf accessed March 2015 32 O'Donnell DE, Aaron S, Bourbeau J, Hernandez P, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease 2007 update. Can Respir J. 2007 Sep;14 Suppl B:5B-32B. 33 Criner GJ, Bourbeau J, Diekemper RL,et al. Executive Summary: Prevention of Acute Exacerbation of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. Chest. 2015 Apr 1;147(4):883-93. 34 McCrory DC, Brown CD. Anti-cholinergic bronchodilators versus beta2-sympathomimetic agents for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2002; :CD003900.

35 Leuppi JD, Schuetz P, Bingisser R, Bodmer M, Briel M, Drescher T, Duerring U, Henzen C, Leibbrandt Y, Maier S, Miedinger D, Mller B, Scherr A, Schindler C, Stoeckli R, Viatte S, von Garnier C, Tamm M, Rutishauser J. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA. 2013 Jun 5;309(21):2223-31. doi: 10.1001/jama.2013.5023. PubMed PMID: 23695200. 36 Global Strategy for Diagnosis, Management, and Prevention of COPD Update 2015 http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html accessed March 2015 37 Mapel, Douglas W., David Dedrick, and Kourtney Davis. Trends and cardiovascular co-morbidities of COPD patients in the Veterans Administration Medical System, 19911999. COPD: Journal of Chronic Obstructive Pulmonary Disease 2005 2(1):35-41. 38 Celli BR et al. Predictors of Survival in COPD: More than Just the FEV1. Respir Med 2008;102(Suppl 1):S27. 39 Hansen-Flaschen, John. "Chronic obstructive pulmonary disease: the last year of life." Respiratory care 49.1 (2004): 90-98. 40 Lanken, Paul N., et al. "An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses." American journal of respiratory and critical care medicine 177.8 (2008): 912-927. 41 Emanuel EJ. Palliative and End-of-Life Care. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015. 42 Lueppi JD, Schuetz P, BingisserR, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the

REDUCE randomised clinical trial. JAMA 2013;309:2223-31

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