COPD Pharm Flashcards
(25 cards)
SABA side fx
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)
SAMA side fx
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
Strong support for initiating ICS with these factors (4)
- history of hospitalization(s) for AECOPD
- > 2 moderate AECOPD per yr
- blood eosinophils >300 cells/uL
- hx of or concomitant asthma
Consider use of ICS (2)
- 1 mod AECOPD per year
- blood eosinophils 100-300
Against Use of ICS (3)
-repeated pneumonia event
-blood eosinophils <100
-history of mycobacterial
infection
ICS benefits?
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
ICS side fx
Oropharyngeal candidiasis (thrush), dysphonia, sore mouth, sore throat
● Systemic SE of long term treatment with high dose ICS
Step therapy
Group A (MMRC 0-1, CAT<10, 0-1 exac)
what is initial therapy?
next step?
- A SABD (prn) or LABD
- Continue if symptomatic benefit documented D
Step therapy
Group B (MMRC >/= 2, CAT >/= 10, 0-1 exac)
what is initial therapy?
next step?
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
Step therapy
Group C (MMRC 0-1, CAT< 10, >= 2 or >= 1 leading to hospital admin exac)
what is initial therapy?
next step?
LAMA (superior to LABA in this grp)
- If persistent exacerbations step up to LABA+LAMA
- LABA/ICS if asthma/COPD overlap
Step therapy
Group D (MMRC >=2, CAT >/= 10, >= 2 or >= 1 leading to hospital admin exac)
what is initial therapy?
next step?
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
Oral corticosteroids: Prednisone
see side fx
- 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
Phosphodiesterase inhibitors: Roflumilast (Daxas®)
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
Oral/iv methylxanthines
Theophylline oral/aminophylline intravenous
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
define AECOPD = lung attack
causes?
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
Consequences of AECOPD
see signs and symptoms
● Increased mortality ● Negative impact on QoL ● Accelerated lung function decline ● Impact on symptoms and lung function ● Increased economic costs
AECOPD Classification
3 cardinal symptoms
Cardinal symptoms include:
● worsening of dyspnea,
● increase in sputum volume
● increase in sputum purulence
AECOPD Classification
mild?
how to treat?
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
AECOPD Classification
moderate?
how to treat?
2 cardinal symptoms
Treated with steroids +/- ABX
AECOPD Classification
severe?
how to treat?
3 cardinal symptoms
ER or hospitalized
AECOPD non-pharm
Oxygen: titrate to improve hypoxemia with target O2 saturation of 88-92%
● Non-invasive mechanical ventilation – consider for acute respiratory failure
AECOPD Pharmacologic Treatment
3 things
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
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
amoxicillin
doxycycline
trimethoprim/sulfamethoxazole
Treat for 5-7 days
Evidence indicates 5 days may be as effective as 7-10 days
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
Amoxicillin- clavulanate
Cefuroxime
Levofloxacin
alternatives: azithromycin, clarithromycin
- Failure of first line agents: improvement following completion of ABX therapy OR clinical deterioration after 72 hrs of ABX therapy
- Use a different class than was used previously
- 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
- macrolides poor Haemophilus coverage and significant S. pneumoniae resistance (more anti-inflamm properties)
