Chronic Obstructive Pulmonary Disease (COPD) 2024.pdf

Therapeutics I Abdulrazzaq Y. A. Al Khazzan Chronic Obstructive Pulmonary PhD. Clinical Pharmacy Assistant professor, Faculty of Disease (COPD) Pharmacy, UST, Sana'a, Yemen Learning Objectives Upon completion the lectures of this...

Therapeutics I Abdulrazzaq Y. A. Al Khazzan Chronic Obstructive Pulmonary PhD. Clinical Pharmacy Assistant professor, Faculty of Disease (COPD) Pharmacy, UST, Sana'a, Yemen Learning Objectives Upon completion the lectures of this lecture, the student will be able to: 1. Describe the pathophysiology of chronic obstructive pulmonary disease (COPD). 2. Assess a patient for signs and symptoms of COPD. 3. List the treatment goals for a patient with COPD. 4. Design an appropriate COPD maintenance treatment regimen. 5. Design an appropriate COPD exacerbation treatment regimen. 6. Develop a monitoring plan to assess effectiveness and adverse effects 7. Formulate an appropriate education plan for a patient with COPD. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 2 Chronic Obstructive Pulmonary Disease (COPD) ❖COPD is a progressive disease characterized by airflow limitation that is not fully reversible. It is caused by exposure to noxious particles or gases, most commonly cigarette smoke. It is a major cause of morbidity and mortality 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 3 Chronic obstructive pulmonary disease (COPD) ▪Chronic bronchitis is a chronic productive cough for at least 3 months in each of two consecutive years in a patient in whom other causes have been excluded. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 4 Chronic obstructive pulmonary disease (COPD) ▪Emphysema is permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 5 Etiology ✓ Cigarette smoking ✓ Occupational exposure to dusts and chemicals (vapors, irritants, and fumes) also plays a role. ✓ Asthma and airway hyper-responsiveness as risk factors. ✓ Hereditary deficiency of α1-antitrypsin (AAT). ✓ Recurrent infections or exposure to tobacco smoke. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 6 Pathophysiology ❑Chronic inflammation in the lung from repeated exposure to noxious particles and gases is primarily responsible for these changes. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 7 Pathophysiology An imbalance between proteinases and antiproteinases in the lung. Inflammation is present in the lungs of all smokers. In COPD the primary inflammatory cells include neutrophils, macrophages. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 8 Pathophysiology Activated inflammatory cells release a variety of mediators (leukotriene B4, interleukin-8, ). Various proteinases, such as elastase, cathepsin G, and proteinase- 3, are secreted by activated neutrophils. These mediators and proteinases are capable of sustaining inflammation and damaging lung structures. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 9 Pathophysiology Deficiency of AAT results in unopposed proteinase activity, which promotes destruction of alveolar walls and lung parenchyma, leading to emphysema. Mucus hypersecretion and ciliary dysfunction lead to chronic cough and sputum production. The major site of airflow obstruction is the peripheral airways (small bronchi and bronchioles with an internal diameter < 2 mm). 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 10 Pathophysiology of COPD 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 11 Diagnosis oPatient’s symptoms and/or history of exposure to risk factors. oSpirometry is required to confirm the diagnosis. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 12 Clinical Presentation of COPD Symptoms Chronic cough (duration greater than 3 months), chronic sputum production; and dyspnea on exertion. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 13 Signs -Paradoxical movements of the chest and abdomen “see-saw”, pursed-lips breathing (“barrel chest”). -Wheezing. -Hypoxemia may include cyanosis and tachycardia. -Signs of cor pulmonale, jugular venous distention (JVD) 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 14 Laboratory tests ▪Hematocrit (˃55%; polycythemia). ▪Normal or ↑ PaCO2 ▪↓ PaO2 ▪↓An α1-antitrypsin level 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 15  Pharmacotherapy treatment algorithm for COPD 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 16 Pharmacotherapy treatment algorithm for COPD 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 17 Treatment Desired Outcomes 1. Smoking cessation if applicable, 2. Reducing symptoms, 3. Preventing and treating exacerbations 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 18 General approach to treatment Nonpharmacologic Therapy -Smoking cessation -Pulmonary rehabilitation. -Long-Term Oxygen Therapy -Surgery [lung volume reduction surgery, and lung transplantation] 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 19 Pulmonary rehabilitation ▪A comprehensive pulmonary rehabilitation program should include exercise training, nutrition counseling, and education. ▪The minimum length of an effective program is 2 months; the longer the program, the more sustained the results. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 20 Long-term oxygen therapy ▪Long-term administration of oxygen (> 15 hrs/day) to patients with chronic respiratory failure has been shown to reduce mortality and improve quality of life. ▪Initiated in stable patients with COPD who have Pao2 ≤ 55 mm Hg or Sao2 ≤ 88%, or with evidence of pulmonary HTN, peripheral edema suggesting HF, or polycythemia. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 21  Recommended initial pharmacotherapy for stable COPD 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 22 Pharmacologic therapy of stable COPD Bronchodilator drugs commonly used in COPD include β2- agonists, anticholinergics, and theophylline. (1) Beta2-Agonists -The short-acting β-agonists include albuterol and terbutaline. -Long-acting β2 -agonists include salmeterol and formoterol. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 23 (1) Beta-2 Agonists Salmeterol: a slower onset of action 10 - 60 min. Formoterol: onset 1-3 min -Bronchodilator effects of both last at least 12 hours. -Adverse effects of β2-agonists are dose-related and include palpitations, tachycardia, and tremor. -Sleep disturbance may also occur and appears to be worse with higher doses of inhaled long-acting β2-agonists. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 24 (2) Anticholinergics Ipratropium and tiotropium are (inhaler) commonly used for COPD. Tiotropium has a half-life ˃ 36 hrs (first-line therapy), OD. Ipratropium half-life of about 2 hours, given every 6 to 8 hours. Inhaled anticholinergics adverse effects are dry mouth, metallic taste, constipation, tachycardia, blurred vision, urinary retention. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 25 (3) Theophylline It has a modest bronchodilator effect in patients with COPD, and its use is limited due to: -A narrow therapeutic index (5-15mg/L), -Multiple drug interactions, and adverse effects. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 26 (3) Theophylline Theophylline should be reserved for patients -Who cannot use inhaled medications or -Who remain symptomatic despite appropriate use of inhaled bronchodilators. The most common adverse effects include heartburn, restlessness, insomnia, irritability, tachycardia, and tremor. Dose-related adverse effects include N/V, seizures, and arrhythmias. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 27 Bronchodilators ❖Patients with COPD often need maintenance treatment with 2 or 3 bronchodilators. ❖Combining albuterol plus ipratropium, a long-acting β2-agonist plus theophylline, or a long acting β2-agonist plus tiotropium produces a greater change in spirometry than either drug alone. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 28 Pharmacologic therapy of stable COPD Corticosteroids ▪In symptomatic patients with severe COPD and frequent exacerbations, regular treatment with inhaled corticosteroids decreases the number of exacerbations per year and improves health status. ▪Reassess 6 to 8 weeks to determine whether there has been a positive response. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 29 Corticosteroids Appropriate situations for corticosteroids in COPD include: (1) short-term systemic use for acute exacerbations and (2) inhalation therapy for chronic stable COPD. Chronic systemic corticosteroids should be avoided in COPD management because of questionable benefits and high risk of toxicity. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 30 Pharmacologic therapy of stable COPD Immunizations ▪Serious illness and death in COPD patients can be reduced by about 50% with annual influenza vaccination. ▪All patients with COPD should also receive a one-time vaccination with the pneumococcal polysaccharide Vaccine. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 31 Pharmacologic therapy of stable COPD Alpha1-antitrypsin augmentation therapy ▪Intravenous augmentation therapy for individuals with AAT deficiency and moderate airflow obstruction. ▪Augmentation therapy consists of weekly transfusions of pooled human AAT with the goal of maintaining adequate plasma levels of the enzyme. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 32 Pharmacologic therapy of COPD exacerbations Commonly reported symptoms are -Worsening of dyspnea, -Increased sputum production, -Change in sputum color. Causes are -Respiratory infection -Air pollution, 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 33 Pharmacologic therapy of COPD exacerbations Mild exacerbations can often be treated at home -with an increase in bronchodilator therapy -with or without oral corticosteroids. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 34 Pharmacologic therapy of COPD exacerbations Moderate to severe exacerbations - Require management in the emergency. - Management should consist of 1. Controlled oxygen therapy, 2. Bronchodilators, -Albuterol is the preferred because of its rapid onset. -Ipratropium added to allow for lower doses of albuterol. 3. Oral or IV corticosteroids, 4. Antibiotics if indicated, 5. Mechanical ventilation (non-invasive or invasive). 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 35 Outcome evaluation ▪Check inhaler technique and adherence at every visit. ▪Monitor patients for improvement in symptoms. ▪Annual spirometry to identify patients who are declining quickly. ▪The mMRC dyspnea scale can be used to monitor physical limitation due to breathlessness. ▪Monitor theophylline levels with goal serum concentrations of 5 to 15 mcg/mL ▪Monitor the patient for adverse effects of the medications selected. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 36 Assessment Questions 1. All of the following play a role in the pathophysiology of COPD except: A. Chronic inflammation from repeated exposure to noxious particles and gases B. An imbalance between proteinases and antiproteinases C. Inflammation similar to what is seen in asthma, which is mainly mediated through eosinophils and mast cells D. Oxidative stress E. Impairment of the normal protective and repair mechanisms in the lungs 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 37 Assessment Questions 2. In COPD, where in the lungs is the primary site of obstruction? 3. A 67-year-old man presents to his primary care physician complaining of productive cough and dyspnea on exertion for the past 6 months; COPD is suspected. Which of the following further supports the diagnosis of COPD? A. A 45 pack–year history of smoking D. FEV1/FVC of 60% (0.60) B. Fifteen years of employment in a plastics plant with exposure to talc C. Family history of AAT deficiency E. All of the above 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 38 Assessment Questions 4. Which of the following is an adverse effect of tiotropium? A. Hypokalemia B. Dry mouth C. Insomnia D. Irritability E. Seizures 5. Which of the following interventions might be appropriate for a patient with moderate (GOLD 2) COPD currently using only an albuterol MDI? A. Oxygen therapy for 16 hours per day B. Two weeks of pulmonary rehabilitation C. Surgery (eg, bullectomy) D. Lung transplantation E. All of the above would be considered appropriate interventions 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 39 References 1. Chisholm-Burns MA, Wells BG, Schwinghammer TL. Pharmacotherapy principles and practice: 6th edition. McGraw-Hill; 2022 2. Wells BG ,DiPiro J, Schwinghammer T, DiPiro C. Pharmacotherapy handbook 12th edition. New York: McGraw-Hill Education; 2023. 3. Joseph T. DiPiro, et al, Pharmacotherapy: A Pathophysiologic Approach, McGraw-Hill Education, 12th Edition 2021. 4. Zeind CS, Carvalho, Michael G.,. Applied therapeutics : the clinical use of drugs. 11th Edition: Wolters Kluwer Health,; 2018. 7/25/2024 DR. ABDULRAZZAQ Y. AL KHAZZAN 40