COPD and Smoking Cessation Lecture PDF

Pharmacotherapy I: COPD/Smoking Cessation Augsburg PA Program, 2024 Samuel Schieffer, PharmD  Learning Objectives Given a clinical scenario, initiate appropriate medication therapy based upon the GOLD classification of COPD Identify goals of therapy for COPD Appropriatel...

Pharmacotherapy I: COPD/Smoking Cessation Augsburg PA Program, 2024 Samuel Schieffer, PharmD  Learning Objectives Given a clinical scenario, initiate appropriate medication therapy based upon the GOLD classification of COPD Identify goals of therapy for COPD Appropriately manage an acute COPD exacerbation For the following representative medications, know the medication class, mechanism of action, route of medication administration, indications, adverse effects Albuterol Ipratropium Salmeterol Tiotropium Salmeterol/fluticasone Prednisone  Other objectives Prescribing Key Points: 1. Understand the Mechanism of Action (MOA) 2. Be mindful of comorbidities 3. Keep in mind the “Big Picture” This Photo by Unknown Author is licensed under CC BY-NC Abbreviations Guide  Meet Our Patient Mr. Joe Camel (JC) is a 68 year old male returning for f/u after an ER visit where he was treated for a suspected COPD exacerbation. He has not been diagnosed with any formal pulmonary disease. Has chronic cough, occasional dyspnea with exertion. Was prescribed albuterol MDI PRN and prednisone 40 mg x 5 days. Tobacco use: smoked 2 ppd x 20 years – quit 2 years ago Alcohol: none PMH T2DM HTN What is it? Optimizing the Role of the of Clinical Pharmacy Specialist (CPS) in Pain Management COPD Burden  Features of COPD Common Preventable Treatable 1. Airflow Limitation 2. Abnormal Inflammation 3. Increased mucous  Pathophysiology Chronic Emphysema Bronchitis COPD This Photo by Unknown Author is licensed under CC BY-SA-NC Pathophysiology Pathophysiology Risk Factors  COPD Signs and Symptoms Constant Coughing Shortness of breath (especially with activity) Inability to breath easily/take a deep breath Excess Mucous production Wheezing  Diagnosis https://www.merckmanuals.com/professional/pulmonary-disorders/chronic-obstructive-pulmonary-disease-and-related-disorders/chronic-obstructive-pulmonary-disease-copd https://www.livingwellwithcopd.com/en/what-is-copd.html  Spirometry Objectively measures forced expiration efforts to measure airflow obstruction Noninvasive, cost effective, readily available Measurements: Fforced vital capacity (FVC) Forced expiratory volume over 1 second (FEV1) FEV1/FVC ratio This Photo by Unknown Author is licensed under CC BY-SA Spirometry Spirometry GOLD Criteria Initial Assessment  Mr. Camel Mr. Joe Camel (JC) is a 68 year old male returning for f/u after an ER visit where he was treated for a suspected COPD exacerbation. He has not been diagnosed with any formal pulmonary disease. Has chronic cough, occasional dyspnea with exertion. Was prescribed albuterol MDI PRN and prednisone 40 mg x 5 days. Tobacco use: smoked 2 ppd x 20 years – quit 2 years ago Alcohol: none PMH T2DM HTN What’s next?? This Photo by Unknown Author is licensed under CC BY-SA Mr. Camel This Photo by Unknown Author is licensed under CC BY-SA Modified Medical Research Counsel Dyspnea Scale COPD Assessment Test  Non-Pharmacologic Therapies Non-Pharm strategies are very important in treatingg COPD: - Smoking Cessation - Vaccines - COPD action plan - Pulmonary Rehab - Oxygen Therapy Smoking Cessation This Photo by Unknown Author is licensed under CC BY  Vaccines Vaccine Recommendation Notes Pneumococcal COPD Pts 19-64 *Various COPD Pts >/= 65 formulation see CDC for details Influenza Annually for all Quadrivalent if >65 RSV >60 at high risk Various forms All Patients >75 Abrysvo Now 18-59 at high risk COVID Currently annually* Dynamic area -> see CDC each year This is in addition to all other routine vaccinations for patient’s age - Recommended CDC Vaccination and Immunization schedule: www.cdc.gov/vaccines.  Pulmonary Rehab What is it? - A program designed to help pt’s learn to breath and function at the highest level with exercise, support, and education Benefits? - Increased muscle strength - Increased Quality of life and exercise capacity - Decreased Dyspnea *Most importantly  Timely rehab within 4-12 weeks of COPD hospitalization REDUCES mortality  Oxygen Therapy Oxygen Therapy: Indicated when Sa O2 90% Long term use increases survival in those with chronic hypoxemia at rest Does NOT improve survival in those with stable COPD, moderate resting, or exercise induced desaturation Aerobika Device  Medications INHALERS: Long acting Anti-Muscarinic (LAMA Long acting Beta-Agonist (LABA) Inhaled Corticosteroids (ICS) Short Acting Beta-Agonist (SABA) Non-Inhaler Medications: Expectorant medications Immune modulators Theophylline Antibiotics Systemic Steroids  Types of Inhalers Meter Dose Inhalers (MDIs) Dry Powder Inhalers (DPIs) Handihaler (not really used much) Respimat/Soft-mist inhalers (mostly replaced handihalers)  Meter Dose Inhalers 80-89% of patients used MDI incorrectly Only 62% of patients were able to breathe in while activating the inhaler Further exaggerated in children and elderly Particularly during an exacerbation Propellant is driving force Requires a slow, deep inhalation Requires priming with first dose or after a long period of non use  Meter Dose Inhalers 1. Remove the cap and hold inhaler upright 2. Shake the inhaler for 5 seconds immediately before using 3. Breathe out fully. 4. Place mouthpiece of inhaler into mouth and close lips around it 5. Press down on the inhaler to release medication as you start to breathe in slowly. 6. Breathe in slowly (over 3-5 seconds) 7. Hold breath for 10 seconds to allow medicine to reach deeply into the lungs. 8. Repeat puffs as directed. - Waiting 1 minute between puffs may permit second puff to penetrate the lungs better Meter Dose Inhalers  Spacers/Aerochambers Enhanced clinical effect in those with poor hand-lung coordination No clinical advantage in those who optimally use MDIs Decreases oropharyngeal deposition May reduce hoarseness and thrush  Dry Powder Inhaler Not dependent on patient coordination In general, can be used in children 5 & up; possibly age 3 or 4 Technique different No spacer Sliding lever or opening cap loads the dose Do not blow into inhaler or cover vent Do not shake or turn upside down Inhalation is rapid (over 1-2 seconds) and deep  HandiHaler Considered a DPI but works differently Powder is contained with a capsule that you load into inhaler Steps for use: 1. Open the Handihaler device 2. Load a Spiriva capsule into chamber 3. Press the piercing button 4. Turn head away from inhaler and breathe out fully 5. Raise inhaler horizontally and inhale deeply and fully 6.Must inhale twice from each capsule to get full dose  Respimat inhaler (soft mist inhaler) Delivers a slow moving mist Steps (T.O.P.) 1.Turn base until you hear a click 2.Open the cap and close your lips around the mouthpiece 3.Press the dose-release button and inhale slowly  Nebulizers Can be used in children/adults who cannot use an MDI especially during exacerbations  Beta-2 Agonists Mechanism of Action: Stimulate B2 receptors Adenyl Cyclase increases cAMP  end result = bronchial smooth muscle relaxation Delivery: Inhalation (MDI or Nebulizer) Short acting (SABA)  MDI or nebulizer Long acting (LABA)  Variety of types Adverse effects: Tremor Tachycardia Palpitations Possible transient effects  Hyperglycemia, hypokalemia, hypomagnesemia  SABA Inhalers Medications: Albuterol (ProAir, Ventolin) 1-2 puffs Q4-6 hours PRN SOB or wheezing Up to 4-8 puffs Q20Min x 3 doses Levalbuterol (Xopenex) Same dosing Purified isomer meant to cause less tachycardia Onset = 5 minutes Peak: 15-30 minutes, duration ~4 hours Available as MDI and Nebulized solutions  Long Acting Beta-2 Agonists (LABA) Mechanism: Long term stimulation of Beta-2 Receptors Medications: Salmeterol Formoterol Olodaterol Vilanterol Onset: Minutes – Hours Duration: 12-24 Hours  LABAs Med Dose Type Other Notes Olodaterol 2.5 mcg – 2 Respimat Single inhaler or puffs daily combination Vilanterol N/A Combination only Only available as part of a combo inhaler Formoterol 20 Mcg BID Nebulized Single nebulized solution Combo inhalers *Quick onset Salmeterol 50 mcg BID DPI Single inhaler or in combination  FDA on LABAs in Asthma The use of LABAs is contraindicated without the use of an asthma controller medication such as an inhaled corticosteroid. Single-ingredient LABAs should only be used in combination with an asthma controller medication; they should not be used alone. LABAs should only be used long-term in patients whose asthma cannot be adequately controlled on asthma controller medications. LABAs should be used for the shortest duration of time required to achieve control of asthma symptoms and discontinued, if possible, once asthma control is achieved.  Muscarinicc Antagonists MOA: Competitively block muscarinic receptors in lungs causing bronchodilation Protect against cholinergic mediated bronchoconstriction Slower onset of action and longer duration of action than Beta-2 agonists Adverse effects: dry mouth and metallic taste; possible risk of systemic anticholinergic adverse effects, e.g. blurred vision, constipation, urinary retention Caution with narrow angle glaucoma, myasthenia gravis, BPH  Short Acting Muscarinic (SAMA) Medication(s): Ipratropium (Atrovent) Inhaler or nebulized Onset = 15 minutes Peak: 1-3 hours Duration: 24-48 Hours Dose: 2 puffs (0.5 mg neb) every 4-6 hours PRN SOB - Can use every hour up to 3 doses *Do not pair with a long acting muscarinic antagonist  Long Acting (LAMA) Medication(s): 1. Tiotropium 2.5 mcg – 2 puffs daily (Spiriva) - Respimat 2. Umeclidinium 62.5 mcg – 1 puff daily (Incruse Ellipta) - DPI Onset: 60 minutes Peak: 1.5-3 hours Duration: 24-48 hours *Do not pair with SAMA medications  Corticosteroids MOA: Reduce airway inflammation by inhibiting or inducing production of proteins Reduced airway inflammation Decreases airway hyperresponsiveness Can be given by inhalation (inhaled corticosteroids) or systemically  Steroids - AEs Inhaled: Systemic: - Fluid retention - Dysphonia - Muscle weakness - Ulcers - Oral Thrush - Insomnia - Impaired wound healing - Cough/Throat irritation - N/V, HA, incr appetite - Osteoporosis - Iincreased risk of pneumonia - Cataracts - Glaucoma - Diabetes - Adrenal insufficiency - Psychosis  Inhaled Corticosteroids - Examples: Fluticasone (Flovent®), Budesonide (Pulmicort®), Mometasone (Asmanex®), Beclomethasone (Qvar®) - Onset and Duration: highly variable - Peak: 1 to 2 weeks with consistent use - MDI, nebulized, and DPI inhalers – often in combination with others - NEVER used as standalone therapy in COPD  Inhaled Corticosteroids High dose ICS have significantly less potential than oral systemic corticosteroids to cause adverse effects Use of ICS can kill off normal flora in the mouth -> fungal growth -> thrush Counsel patient to rinse mouth with water after each use  Inhaled Corticosteroids **Variety of combo inhalers including ICS Beyond Inhalers  Theophylline MOA: Blocks phosphodiesterase which  cAMP. Relaxes smooth muscle of bronchi and pulmonary blood vessels. Stimulates respiratory center and enhances ADL’s in patients with severely limiting COPD. May be beneficial for nocturnal dyspnea. Metabolism by liver, excreted by kidney. Plasma t½ shorter in smokers; clearance  in elderly Slow onset of action - not for acute symptoms. Usually dosed once or twice daily, commonly once daily in evening for nocturnal dyspnea. Brand names: Theo-Dur, Slo-Bid, Slo-Phyllin, Theo-lair  Theophylline Many drug/drug, drug/disease interactions. Need to monitor levels regularly (therapeutic range for COPD is 8-12 mg/L) Usual starting dose: 300-600 mg/day (dosed every 6-8 hours) Adverse effects: restlessness, insomnia, gastroesophageal reflux during sleep, palpitations, potentiation of diuresis Signs of toxicity >20mg/L: 75% of patients experience adverse reactions such as N,V,D, H/A, insomnia, irritability >35mg/L: hyperglycemia, hypotension, atrial tachycardia, ventricular arrythmias, refractory seizures  Leukotriene Modifiers Anti-inflammatory medications that Inhibit 5-lipoxygenase (zileuton) Competitively antagonize the effects of leukotriene (montelukast and zafirlukast) Improve FEV1 and decrease asthma symptoms, SABA use, and exacerbations Montelukast – well tolerated  10 mg daily Zafirlukast and zileuton require liver monitoring (hepatotoxicity), and CYP 2C9  Leukotriene Modifiers Benefits (not a good as ICS) Improve lung function Decrease the need for short-acting B2 agonists Prevent exacerbations Indications Exercise induced asthma Seasonal and perennial allergic rhinitis Adverse effects (Montelukast): Neuropsychiatric effects (FDA warning) Unclear mechanism Actual correlation is debated Appears to be reversible with discontinuation Adjunct therapies  Symptom management Allergy Medications: - Loratadine or Cetirizine 10 mg daily Expectorants -Guaifenesin 200-600 mg TID (Mucinex) *Unclear efficacy This Photo by Unknown Author is licensed under CC BY-NC-ND  GOLD Guidelines The “GOLD” standard: Global Initiative for Chronic Obstructive Lung Disease (GOLD); http://www.goldcopd.org Updated annually Major change from 2017+2023 to the 2024 updates Initial Treatment – Gold Group A GROUP A Inhalers Gold Group B GROUP B Inhalers Gold Group E  GROUP E Inhalers OR LAMA or LABA or LAMA/LA BA LAMA Treatment Summary - Inhalers ICS Treatment The Treatment Cycle Ongoing Review of Therapy Single combination inhalers may be more effective and improve adherence Consider to de-escalate ICS if pneumonia or other adverse effects  Inhaler Keys Clinical Pearls: At each step  assess ADHERENCE Proper training for inhalers is KEY (pharmacists?) Assess inhaler technique along with adherence  Goals of therapy Reduce Symptoms Relieve symptoms Improve exercise tolerance Improve health status Reduce Risk Prevent disease progression Prevent and treat exacerbations Reduce mortality ICS Deprescribing  Asthma/COPD overlap Assess all symptoms If more asthma-like symptoms MART/SMART therapy LABA/ICS  BID or PRN or a combination of both Usually with Symbicort (Budesonide/formoterol) If more COPD in nature Can do LABA/ICS (i.eFluticasone/salmeterol) or Triple therapy  Mr. Camel After further assessment of JC, he reports this was his first exacerbation. CAT score = 18 today. No EOS on file  Mr. Camel JC comes back 6 months later. He has had another exacerbation and ended up in the hospital. CAT score = 12 today. Blood EOS 1 month ago = 325 cells/uL.  COPD Exacerbations Why do we care? Exacerbations Exacerbations Where to Treat? Exacerbations  SABA + SAMA USE Medications: - SABA  Albuterol inhaler or nebs - SAMA  Ipratropium (albuterol or nebs) - SABA/SAMA  Nebulizer (DuoNeb's) or Inhaler (Combivent)  To Antibiotics or To Not Antibiotics Cardinal Symptoms = Increased sputum, Increased sputum purulence, dyspnea  Exacerbation medications Antibiotics: - Doxycycline, Azithromycin, or Azithromycin - Duration = 5-7 days Steroids: - Usually Prednisone 40 mg x 5 days - No taper needed Exacerbation Keys Post Exacerbation  Next up This Photo by Unknown Author is licensed under CC BY-SA  Smoking Cessation Discuss the frequent symptoms of nicotine withdrawal. Describe appropriate follow up after prescribing smoking cessation For the following medications, know the medication class, mechanism of action, indications, adverse effects, contraindications, special considerations, monitoring and patient education. Nicotine patch Nicotine gum Bupropion Varenicline  Smoking = Bad Approximately 1 in 5 adults in the US use tobacco 2/3 of smokers say they want to quit >50% of smokers report that they tried to quit in the past year 3 -6% percent of smokers who make an unaided quit attempt are still abstinent one year later. > other therapies Counseling Helps 5 A’s  Patients Who Are Not Ready?  5 R’s Strategies if not ready to quit: - Use motivational interviewing - Ask open-ended questions - Use reflective listening - Aks for permission to provide information - Emphasize personal choice and control Always in Combination  Behavioral and Other Resources Providing counseling support and mental health support while quitting smoking Support groups 1-800-QUIT-NOW or 1-800-784-8669 Supporting the HABIT of smoking: Substitute for other oral fixators (gum, mints etc) Dole out certain amount per day and taper down DEADs strategy (Delay, Escape, Avoid, Distract, or Substitute) Go for a walk, game on the phone, talked to a support person Behavioral Support and therapy improve success! Common Questions  Medications Varenicline (Chantix) Nicotine Replacement Therapy Bupropion SR (Zyban) Second line pharm options Clonidine, Nortriptyline This Photo by Unknown Author is licensed under CC BY-NC-ND First Line Therapy  Varenicline (Chantix) Alpha-4-beta-2 nicotinic acetylcholine receptor agonist Selectively blocks this receptor Mechanism of Action Partial stimulation of the nicotinic receptor helps reduce the severity of the smoker's craving and withdrawal symptoms from nicotine Varenicline stimulates dopamine activity but to a much smaller degree than nicotine does, resulting in decreased craving and withdrawal symptoms If a person smokes a cigarette while receiving varenicline, the sense of satisfaction associated with smoking may potentially be decreased  Varenicline (Chantix) Dose adjustments: 0.5 mg BID if CrCl