COPD

Define COPD

•Chronic Obstructive Pulmonary Disease

→Common, preventable, treatable

1)Airflow limitations

2)Abnormal inflammatory response

3)Increased mucus production

Progressive disease worsens over time

Persistent respiratory symptoms (this is different that asthma)

Describe how COPD can impact patient’s daily lives

•Difficulty with physical activities

•May not be able to wrok

•Hard to engage in social activities

•Increased confusion, memory loss, depression

•More emergency room visits

Is COPD more or less prevalent in rural communities?

•More prevalent (Double)

How does COPD prevalence and disease severity differ among females versus in males? How does COPD prevalence differ across ethnicity?

•More females die from COPD, and COPD is likely underdiagnosed in women

•Inequities across ethnicities most notable being American Indian and Alaskan Native descent

Describe the characteristics of patients in Wisconsin with COPD.

•Above the age of 65

•Less than a high school diploma

•Low income

•Divorced/widowed/separated

•Current or former smoker

•Have had asthma

What are the two underlying disease processes that lead to COPD?

Emphysema

Chronic Bronchitis

Emphysema

•Destruction of lung parenchyma leads to decreased lung elastic recoil

Symp: SOB, wheezing

Chronic Bronchitis

•Mucus overproduction leading to inflamed narrow airways, cilia destruction

Symp: Cough, mucus, wheezing

What impact can COPD have on lung parenchyma? What is the outcome of this?

•Destruction of lung parenchyma leads to decreased lung elastic recoil

What is the test that is required to diagnose COPD? What are the specific parameters within this test that must be met for a COPD diagnosis?

Spirometry:

FEV1/FVC <0.70

GOLD IV: Very Severe

FEV1 < 30% predicted

GOLD III: Severe

30% < FEV1 <50% predicted

GOLD II Moderate

50% < FEV1< 80% predicted

GOLD I Mild

FEV1>80% predicted

symptoms of COPD

Dyspnea: Shortness of breath

Chronic cough (often first symptom)

Chronic Sputum production

Wheezing, chest tightness

Lower respiratory tract infections

What is the age cutoff for a COPD diagnosis?

40 years old

What are the risk factors for COPD?

Exposure to particles

Socioeconomic status

Age and Sex

Genes

Asthma, chronic bronchitis

Childhood lung development & respiratory infection

What are our goals of therapy for COPD management?

Decrease symtpoms

Prevent disease progression

Prevent and treat exacerbations

Reduce mortality

LAMA nebulizers

Lonhala Magnair Nebulizer→ Glycopyrolate

Yupelri Nebulizer→ Revefenacin

What are the common and rare/severe side-effects of LAMAs?

Common: Dry mouth, bitter taste, nasopharyngitis

Rare: worsening narrow angle glaucoma, worsening urinary retention

Are cardiac risks a significant concern with LAMA use?

NO

What are some considerations regarding use of Yupelri?

Do not give with anticholinergic agents

Do not give with OATP1B1 and OATP1B3 inhibitors

Can LAMAs be used as monotherapy maintenance treatment for COPD?

sure

LABA Nebulizers

Brovana Nebulizer→ Aformoterol

Perforomost Nebulizer → Formoterol

What are the common and rare/severe side-effects of LABAs?

Common: Dry mouth, cough, nasopharyngitis

Rare: can produce sinus tachycardia, cardiac rhythm disturbances

In which type of patient might we consider monitoring more closely for cardiac rhythm disturbances?

QTC prolonging agents may potentiate effects of LABA on CV system

Monitor carefully in patients with CV disorder

Can LABAs be used as monotherapy maintenance treatment for COPD?

CAN be used as monotherapy for mild or moderate COPD

NOT rescue med

What are some unique considerations with Anoro?

Caution with ketoconazole and other strong CYP3A4 inhibitors

Summarize the role of bronchodilators (LAMAs and LABAs) for COPD management. Can they ever be used together? When?

LABA/LAMA combo therapy is commonly used as step up therapy in COPD if a patient remains symptomatic/ increase exacerbations on LAMA or LABA monotherapy

Are ICSs ever used as monotherapy for COPD?

NO

What is the “place in therapy” for ICS/LABA or ICS/LABA/LAMA treatment in COPD?

What was the ETHOS trial, and what did it demonstrate regarding ICS treatment?

Exacerbation reduction with triple therapy as comapred to ICS/LABA and LABA/LAMA

Higher eisoinophil counts may identify pateints with greater likelihood of beneficial ICS response

Describe patient-specific factors that may increase the risk of pneumonia with ICS treatment.

Eosinophil counts

Prior history pnuemonia

Over 55

BMI <25

Current smokers

STRONGLY favors use of ICS

History of hospitalizations for COPD exacerbations

2 or more moderate exacerbations of COPD per year

Blood eosinophils 300 or more

Asthma or history of asthma

FAVORS use of ICS

1 moderate exacerbation of COPD per year

Blood eosinophils 100-300

AGAINST ICS use

Repeated pneumonia events

Blood eosinophils <100

History of mycobacterial infeciton

MMRC

Modified Medical Research Council Dyspnea

→ 0 (minimal dyspnea) to 4 (significant dyspnea)

CAT

COPD Assessment Test

→ <10 low

→ 10-20 medium

→ >20 high

→ >30 very high

Higher score worse

Draw the inital pharmacologic treatment boxes thing

roflumilast side effects, interaction

Side effects: Psychiatric events, Weight loss

Drug interactions: Do not use with strong CYP450 inducers

Contraindications: Liver impairment

Describe specifics regarding azithromycin and when this therapy might be used in COPD management.

Patients with severe COPD who are NOT current smokers. Only been studied for 1 year.

Side effects:

Impaired hearing

QTc prolongation

Increased bacterial resistance

True or false: theophylline, antioxidants, and expectorants are all very effective and safe treatment strategies for COPD management

FALSE