COPD Flashcards
Class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
(COPD) Chronic Obstructive Pulmonary Disease:
- is a progressive disease, NOT fully reversible.
- cigarette smoking causes about 80-90% of ALL COPD cases
- tobacco smoke being the biggest risk factor
- the (AAT) alpha-1 antitrypsin deficiency are also at a higher risk of developing COPD because AAT helps to protect the lungs from damage caused by inflammation. This is another risk factor.
Symptoms:
- dyspnea (shortness of breath)
- chronic cough
- sputum (mucus) production
Medications will help control the symptoms.
BUT we can’t reverse that damage that has already been done.
COPD is preventable.
(COPD) Chronic Obstructive Pulmonary Disease: BACKGROUND
Healthy airways are nice and open, patients are able to breath freely and easily.
What’s happening in COPD is, there’s inflammation of the airways, there’s chronic BRONCHITIS with excess mucus production. And there is EMPHYSEMA, which is the actual breakdown of the alveoli. Alveoli are the grapelike balloon clusters at the ends of the bronchial which allow gas exchange to occur. Damage to the alveoli impairs gas exchange.
bronchitis and emphysema are 2 common subsets of COPD and are part of the disease.
Diagnosis of COPD:
“can be challenging”
- it looks like a lot of other things, someone that comes in with shortness of breath, you might be thinking [heart failure, pneumonia,], although there are tools that help with rule out other comorbidities, it is hard to distinguish from asthma.
- mainly going to be in adults
- due to some kind of exposure/irritate, usually smoke, over a period of time.
- smoking history common
- Sputum production much more prevalent in COPD
_________________________________________________________________________________
- age onset usually greater than > 40 years old
- smoking history usually > 10 years
- sputum production common
- allergies uncommon
- Persistent symptoms (shortness of breath, hard time breathing, is going to be persistent and will worsen over time).**
- Disease worsens slowly over time**
- Exacerbations common*
- *****First Line Tx: _______________
Bronchodilators [beta 2 agonists AND antimuscarinics (anticholinergics)]
** Asthma**
- in younger patients
- often in children
- develop that inflammation early on in life
- age of onset usually less than < 40 years
- smoking history uncommon
- sputum production infrequent
- Allergies common
- Intermittent/variable symptoms**
- Stable disease (does NOT worsen over time)**
- Exacerbations common*
- *****First Line Tx: ________________
inhaled corticosteroids (ICS)
Diagnosis of COPD:
- is done with spirometry which is REQUIRED
- this assesses lung function
-
**specifically for diagnosis you are looking for:
an FEV1/FVC ratio of less than < 0.7, which confirms diagnosis.* - this measures how fast you can exhale AND the maximum amount of air you can exhale. It uses a ratio, and a score of less than 0.7 or 70% confirms diagnosis of COPD.
after diagnosis is confirmed, we don’t really use spirometry after this.
- -We will then use it to determine severity—
We don’t use spirometry for monitoring COPD after. This is done for asthma only**.
Diagnosis of COPD:
Once we have diagnosis of COPD, we can classify severity using the ______________.
We would look at patient’s FEV1 score component alone obtained from the initial diagnosis of COPD from the FEV1/FVC.
GOLD Classification (Grading) System
Degree of Airflow Limitation:
We would look at FEV1 score of patients and compare it to % predicted.
“post-bronchodilator FEV1/FVC”
what are the breakdown classifications of each?
GOLD 1:
GOLD 2:
GOLD 3:
GOLD 4:
GOLD 1: MILD = FEV1 greater or equal to > 80%
GOLD 2: MODERATE = FEV1 less than 80% BUT equal to or greater than 50%
GOLD 3: SEVERE = FEV1 less than 50% BUT equal to or greater than 30%
GOLD 4: VERY SEVERE = FEV1 less than 30%
COPD Assessment:
What we are using to manage the patient throughout their care and monitor them, is more of a SYMPTOMATIC based approach.
- we do this by using validated assessment tools, questionnaires, since patient knows best what their symptoms have been like.
Tests we use:
1)
2)
1)- COPD Assessment Test (CAT)-
Scale is from 0 - 40
40 being the worst
0 being the best
classifies patients symptoms on a scale.
2)- Modified British Medical Research Council (mMRC) dyspnea scale-
Scale is 0-4
Higher number = worse symptoms
we use both to ask the patient How they have been doing.
COPD Assessment:
How do we then use these tools?
We put them into a combined assessment of COPD.
We take information from the 2 tool scales AND their risk of an exacerbation (by looking at their History of exacerbations & how severe they were if present), along with comorbidities. Putting all this in a Combined Assessment.
- Risk of Exacerbations
- Comorbidities
We take both and combine into this assessment to help determine Where to Start Treatment.
Risk (exacerbation Hx)
Symptoms
- as you increase in symptoms, more likely to be in B or D
___________________________________________________________________________________
A) Low symptoms
B) High symptoms
C) Low symptoms, Risk High: 2 or more exacerbations OR 1 exacerbation leading to hospitalization
D) High symptoms, Risk High: 2 or more exacerbations OR 1 exacerbation leading to hospitalization
^
^
^ C / D exacerbations A / B
symptoms---->
(COPD) Chronic Obstructive Pulmonary Disease
Treatment:
Non-drug Tx:
Drug Tx:
Treatment:
Non-drug Tx:
- slow progressive (quit smoking): smoking is what caused the problem, it will only make it worse. If patient doesn’t stop, it will continue the progression of the disease. It will NOT reverse the damage that has already been done BUT it will stop it from that fast progression forward and really slow it down.
-
- vaccinations*
- inhaler technique and adherence
Drug Tx:
- control symptoms [drugs will not cure the disease or slow the progression]
- prevent exacerbations
1st line Bronchodilators
ICS- add on therapy
pulmonary rehabilitation
oxygen
surgery
Treatment algorithm:
Starting with Initial Pharmacologic Therapy: Bronchodilator, Bronchodilator, Bronchodilator!
A: LOW Symptoms / LOW Exacerbation risk
- CAT < 10 or mMRC 0-1
- 0 or 1 exacerbation (NOT leading to hospital admission)
——————————————————————————–
B: High Symptoms / Low Exacerbation risk
(symptoms are more frequent)
- CAT greater than or equal to > 10 OR mMRC greater than or equal to 2
- 0 or 1 exacerbation (NOT leading to hospital admission)
- - - - so it should make sense that we want a long-acting drug to control the symptoms that are happening over time.
——————————————————————————–
C: Low Symptoms/ High Exacerbation Risk
- CAT < 10 OR mMRC 0-1
- greater than or equal to 2 exacerbations OR greater than or equal to 1 exacerbation that lead to hospital admission
D- HIGH Symptoms / HIGH Exacerbation risk
(we want to treat aggressively)
- CAT greater than or equal to 10 OR mMRC is greater than or equal to 2
- ** greater than or equal to 2 exacerbations OR greater than or equal to 1 exacerbation that lead to hospital admission**
A-
Bronchodilator: (SABA) short acting beta-2 agonists or (SAMA) short acting muscarinic antagonists [also called anticholinergics] PRN —– PREFERRED
or some patients LABA or LAMA
——————————————————————————–
B- LABA or LAMA
——————————————————————————–
C- LAMA preferred. Have shown to have decreased risk of hospitalization.
——————————————————————————–
D-
Option 1) LAMA or
Option 2) LAMA + LABA or
Option 3) LABA + ICS [IF eosinophils > greater than or equal to 300 cells/uL]**, some patients will respond better to a steroid since there will be inflammation present. We know inflammation is present by looking at the eosinophils. **
Eosinophils are a marker of Inflammation
Escalation of Treatment:
Think, Why do we need to increase treatment?
1) Is it because patient is having a lot of SYMPTOMS? (SOB) = dyspnea
2) Is it because patient is having a lot of EXACERBATIONS?
1) LAMA or LABA ——–> LAMA + LABA ———> switch inhaler, check for other causes
when stepping up therapy increase dose to recommended max, then add on therapy, if still not controlled may be time to switch inhalers.
——————————————————————————————————————–2)
LAMA OR LABA
LAMA + LABA OR LABA + ICS (if HIGH eosinophils, 300 or greater)
LAMA + LABA + ICS [if eosinophils 100 or greater] OR LAMA + LABA + ICS
(can consider adding on roflumilast or azithromycin- especially if they have smoking history)
An inhaled corticosteroid (ICS) is only recommended in COPD patients with _______________
history of exacerbations and are high risk for exacerbations AND high eosinophil counts (eosinophils > or = 300 cells/microliter).
Long-term monotherapy with oral steroids is ___________
NOT recommended
