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1 Chronic Obstructive Pulmonary Disease: The Pharmacist s Role in Ongoingg Patient Education and Management Presented as a Live Webinar Tuesday, September 17, :00 p.m. 2:00 p.m. EDT Thursday, October 17, :00 p.m. 2:00 p.m. EDT Wednesday, November 6, :00 p.m. 1:000 p.m. EST Planned and conducted by ASHP Advantage and supported by an independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc., and an educational grant from Novartis Pharmaceuticals Corporation

2 Chronic Obstructive Pulmonary Disease: The Pharmacist s Role in Ongoing Patient Education and Management WEBINAR INFORMATION How do I register? Go to and click on the Register button. After you submit your information, you will be ed computer and audio information. What is a live webinar? A live webinar brings the presentation to you at your work place, in your home, through a staff inservice program. You listen to the speaker presentation in real time as you watch the slides on the screen. You will have the opportunity to ask the speaker questions at the end of the program. Please join the conference at least 5 minutes before the scheduled start time for important announcements. How do I process my Continuing Education (CE) credit? Continuing pharmacy education for this activity will be processed on ASHP s new elearning system and reported directly to CPE Monitor. After completion of the live webinar, you will process your CPE and print your statement of credit online at To process your CPE, you will need the enrollment code that will be announced at the end of the webinar. View full CE processing instructions What if I would like to arrange for my colleagues to participate in this webinar as a group? One person serving as the group coordinator should register for the webinar. That group coordinator will receive an confirmation with instructions for joining the webinar. A few minutes before the webinar begins, the group coordinator should launch the webinar link. Once the webinar has been activated, the coordinator will have the option to open the audio via VoIP (Voice Over IP) on the webinar toolbar or use a touch tone phone with the provided dial-in information. At the conclusion of the activity, the group coordinator will complete a brief online evaluation and report the number of participants at that site. Each participant will process his or her individual continuing education statement online. What do I need in order to participate in the webinar? 1. Computer with internet access and basic system requirements. When you register, the webinar system will assess your system to ensure compatibility. 2. Telephone to dial the toll-free number and listen to the presentation (if you choose not to use Voice Over IP [VoIP] via your computer). Webinar System Requirements Be sure to view the webinar system requirements for Windows, Mac, ios, and Android prior to the activity. 2

3 Chronic Obstructive Pulmonary Disease: The Pharmacist s Role in Ongoing Patient Education and Management ACTIVITY FACULTY Sharya Vaughan Bourdet, Pharm.D., BCPS Clinical Inpatient Program Manager and Residency Director Veterans Affairs Medical Center Associate Clinical Professor University of California, San Francisco School of Pharmacy San Francisco, California Sharya Vaughan Bourdet, Pharm.D., BCPS, is Clinical Inpatient Program Manager and Residency Program Director of the postgraduate year 1 (PGY1) residency at Veterans Affairs Medical Center in San Francisco, California. She is also Associate Clinical Professor in the Department of Clinical Pharmacy at the University of California, San Francisco School of Pharmacy. Dr. Bourdet earned her Doctor of Pharmacy degree from the University of California, San Francisco School of Pharmacy and completed a PGY1 pharmacy residency and PGY2 pulmonary/critical care pharmacy residency at University of North Carolina Hospitals and Clinics in Chapel Hill, North Carolina. She is a board-certified pharmacotherapy specialist. Dr. Bourdet is actively involved with teaching students at the University of California, San Francisco Schools of Medicine and Pharmacy and has been nominated for several teaching awards. Her practice interests include the pharmacotherapy of pulmonary diseases, use of sedative agents in the intensive care unit, quality improvement, and patient safety initiatives. She has published book chapters in the area of pulmonary diseases. Before assuming her current position, Dr. Bourdet was Critical Care Pharmacist at Veterans Affairs Medical Center in San Francisco. She continues to serve as a preceptor for PGY1 pharmacy residents and fourth-year pharmacy students from the University of California, San Francisco and University of the Pacific Schools of Pharmacy during critical care rotations. 3

4 Chronic Obstructive Pulmonary Disease: The Pharmacist s Role in Ongoing Patient Education and Management DISCLOSURE STATEMENT In accordance with the Accreditation Council for Continuing Medical Education s Standards for Commercial Support and the Accreditation Council for Pharmacy Education s Guidelines for Standards for Commercial Support, ASHP Advantage requires that all individuals involved in the development of activity content disclose their relevant financial relationships. A person has a relevant financial relationship if the individual or his or her spouse/partner has a financial relationship (e.g., employee, consultant, research grant recipient, speakers bureau, or stockholder) in any amount occurring in the last 12 months with a commercial interest whose products or services may be discussed in the educational activity content over which the individual has control. The existence of these relationships is provided for the information of participants and should not be assumed to have an adverse impact on presentations. All faculty and planners for ASHP Advantage education activities are qualified and selected by ASHP Advantage and required to disclose any relevant financial relationships with commercial interests. ASHP Advantage identifies and resolves conflicts of interest prior to an individual s participation in development of content for an educational activity. The faculty and planners report the following relationships: Sharya Vaughan Bourdet, Pharm.D., BCPS Dr. Bourdet declares that her spouse is an employee and stockholder of Theravance, Inc. Susan R. Dombrowski, M.S., B.S.Pharm. Ms. Dombrowski declares that she has no relationships pertinent to this activity. Carla J. Brink, M.S., B.S.Pharm. Ms. Brink declares that she has no relationships pertinent to this activity. ASHP staff has no relevant financial relationships to disclose. 4

5 Chronic Obstructive Pulmonary Disease: The Pharmacist s Role in Ongoing Patient Education and Management A CTIVITY OVERVIEW This educational activity will explain the role of pharmacists in managingg patients with chronic obstructive pulmonary disease (COPD) such that exacerbations and disease progression are minimized. Emerging treatment options for patients with COPD will be reviewed taking into account evidence-based guidelines aimed at improving care. Strategies for improving medication adherence and ensuring proper inhaler technique will also be explored.. Time for questions and answers from the webinar audience will be provided at the end of the presentation. L EARN ING O BJEC TIVES The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider off continuing pharmacy education. This activity provides 1.0 hour (0.1 CEU) of continuingg pharmacy education credit (ACPE activity # L01-P). Attendees must complete a Continuing Pharmacy Educationn Request online and may immediately print their official statements of continuing pharmacy education (CPE) credit following the activity. Complete instructions for processing CE can be found on the last page of this handout. At the conclusion of this application-based educational activity, participants should be able to Review current evidence-bas sed strategies and emerging treatment options to improve the care of patients with COPD. Outline a plan for developing the pharmacist s role inn managing patients with COPD. Demonstrate proper technique for medication delivery devices that can be taught to patients. Compare the properties of various types of inhalers and best practices with their use. C ONTI NUIN G EDU CATI ON AC CRED ITAT ION 5

6 Chronic Obstructive Pulmonary Disease: The Pharmacist s Role in Ongoing Patient Education and Management Sharya Vaughan Bourdet, Pharm.D., BCPS Clinical Inpatient Program Manager Veterans Affairs Medical Center Associate Clinical Professor UCSF School of Pharmacy San Francisco, California Statistics - Mortality In the U.S., COPD is 3 rd leading cause of death Behind heart disease and cancer Number of deaths due to COPD is higher among women compared with men Number of deaths due to COPD has increased among American Indian/Alaska Native ethnic group Ford ES et al. Chest. 2013; 144: Statistics Resource Use In 2010, there were 10.3 million physician office visits for COPD 1.5 million emergency department (ED) visits for COPD 699,000 discharges related to COPD 2008 costs attributed to asthma and COPD $20.4 billion for prescription medication $13.2 billion for office visits $13.1 billion for hospitalizations $3.1 billion for ED visits Ford ES et al. Chest. 2013; 144: Goals for COPD Healthy People Reduce activity limitations Reduce hospitalizations and ED visits Reduce mortality Global Initiative for COPD (GOLD) 2 Relieve symptoms, improve health status Prevent disease progression Prevent complications Reduce mortality Role of the Pharmacist Prevention of disease progression Optimization of therapy Prevention of complications Patient education Definition COPD is characterized by airflow limitation that is not fully reversible Compare with asthma Airflow limitation is progressive Due to inhalation of noxious particles and inflammatory response Smoking, occupational or environmental exposures 6

7 Severity of Disease Combined assessment of Symptoms Determined by patient questionnaire Degree of airflow limitation Determined by spirometry Risk of future exacerbations Predicted by both symptoms and spirometry Co-morbid conditions Difficult to objectively incorporate Symptoms COPD Assessment Test (CAT) Score of <10 means less symptoms Score of 10 means more symptoms Modified Medical Research Council (mmrc) Dyspnea Questionnaire Score of <2 means less symptoms Score of 2 means more symptoms Symptoms Clinical COPD Questionnaire (CCQ) Score of <1 means less symptoms Score of 1 means more symptoms COPD: Airflow Limitation GOLD 1: Mild FEV 1 80% predicted GOLD 2: Moderate 50% FEV 1 < 80% predicted GOLD 3: Severe 30% FEV 1 < 50% predicted GOLD 4: Very severe FEV 1 < 30% predicted Risk of Future Exacerbations High risk 2 exacerbations in the last year OR FEV 1 < 50% of predicted OR 1 exacerbation requiring hospitalization Low risk < 1 exacerbation in last year AND FEV 1 > 50% of predicted Patient Category A Combined Assessment Determine patient category based on spirometry, exacerbations and/or symptoms. Choose highest risk feature. B C D Description Spirometry Exacerbations in Last Year* Less symptoms; low risk More symptoms; low risk Less symptoms; high risk More symptoms; high risk FEV 1 50% of predicted FEV 1 50% of predicted FEV 1 < 50% of predicted FEV 1 < 50% of predicted CAT mmrc CCQ 0-1 < > 1 2 < > 1 *One or more exacerbations requiring hospitalization equals high risk. See page 15 for enlarged view 7

8 Patient Scenario: TJ TJ is a 73-yo woman who was diagnosed with COPD 3 years ago. She presents to her PCP for a regular visit. Reports using her albuterol MDI 3-4 times per day, depending on activity. She has had one exacerbation in the last year that required an office visit. PFTs: FEV 1 60% of predicted (3 years ago) TJ completed the mmrc questionnaire during this visit and had a score of 2 Which GOLD patient category best describes TJ? a. Patient category A b. Patient category B c. Patient category C d. Patient category D MDI = metered-dose inhaler PFT = pulmonary function test Prevention of Disease Progression No pharmacologic treatment for COPD has been shown to decrease disease progression in all patients Smoking cessation is the most important intervention to stop disease progression Recommended for all GOLD patient categories 1 39% of patients with COPD continue to smoke CDC. MMWR Morb Mortal Wkly Rep. 2012; 61: Effect of Smoking on Lung Function Decline Fletcher C et al. Br Med J. 1977; 1(6077): Reprinted with permission. See page 15 for enlarged view Key Points It is never too late to stop smoking! Patients can be empowered to slow the progression of their disease Pharmacists can assess patients for readiness in various settings Community pharmacy Clinic Before discharge from hospital Optimization of Therapy Ensure patients get pharmacologic treatment when needed 60-70% of COPD patients prescribed NO maintenance medication 5-7% short-acting bronchodilator only Targets: symptom control, prevention of exacerbations Consider individual patient factors when choosing therapy Make BP et al. Int J Chron Obstruct Pulmon Dis. 2012; 7:1-9. 8

9 Inhaled Bronchodilators* SABA: short-acting β 2 agonists Albuterol SAMA: short-acting muscarinic agents** Ipratropium LABA: long-acting β 2 agonists Salmeterol, formoterol, arformoterol, indacaterol LAMA: long-acting muscarinic agents** Tiotropium, aclidinium *Listed here are some examples; see Appendix for more complete list. **Also referred to as anticholinergics. Combination Inhalers* Inhaled corticosteroid (ICS) plus LABA Budesonide/formoterol (Symbicort) Fluticasone furoate/vilanterol (Breo Ellipta) Fluticasone/salmeterol (Advair) Mometasone/formoterol (Dulera) *Listed here are some examples; see Appendix for more complete list. Future Inhaled Therapies Class Medication Device Status LAMA Glycopyrronium Breezhaler Approved by EMA LAMA/LABA Glycopyrronium/indacaterol Breezhaler Under review - EMA LAMA/LABA Umeclidinium/vilanterol Ellipta Under review - FDA Target: Symptom Control Inhaled short-acting bronchodilators Inhaled long-acting bronchodilators Oral theophylline ICS/LAMA/LABA MABA Fluticasone/umeclidinium/ vilanterol Ellipta Phase I trials , LAS190792, AZD2115 Various Phase I and II trials EMA = European Medicines Agency FDA = Food and Drug Administration MABA = muscarinic antagonist β agonist See page 16 for enlarged view Bronchodilators: Short-acting Short-acting bronchodilators effective for asneeded symptom relief Recommend short-acting β 2 -agonist for more rapid onset of activity When to use? As rescue medication for all GOLD patient categories Can be the primary therapy for GOLD patient category A (less symptoms, low risk) Important to assess symptom control AND activity level at healthcare visits Bronchodilators: Long-acting Long-acting bronchodilators more effective than short-acting for symptom relief More convenient dosing Long-acting bronchodilators may be used as monotherapy Compare with asthma When to use? For patients needing more symptom control (GOLD patient category B, D) For patients desiring less frequent dosing 9

10 Bronchodilators: Combinations Benefits of combining bronchodilators from different classes Additional symptom control Decreased risk of adverse effects When to use? For patients requiring additional symptom control For patients complaining of adverse effects due to higher dose of single bronchodilator Target: Prevent Exacerbations Long-acting bronchodilators LABA: long-acting β 2 agonists LAMA: long-acting anticholinergics Inhaled corticosteroids Oral theophylline Oral phosphodiesterase-4 inhibitor (PDE4I) Roflumilast Long-acting Bronchodilators Long-acting bronchodilators decrease exacerbations and hospitalizations LAMA or LABA may be used as monotherapy When to use? For patients at high risk for exacerbations (GOLD patient category C,D) Inhaled Corticosteroids Treatment with ICS improves quality of life and decreases exacerbations in patients with FEV 1 < 60% of predicted Not recommended as monotherapy without long-acting bronchodilator Risk of pneumonia with ICS therapy When to use? For patients at high risk for exacerbations (GOLD patient category C,D) Combination Therapy ICS should be combined with LABA based on available evidence Combination more effective than each alone in preventing exacerbations Triple therapy (LAMA+LABA+ICS) can be considered for additional control When to use? Double therapy GOLD category C,D Triple therapy GOLD category D Patient Category A (Less symptoms; low risk) B (More symptoms; low risk) C (Less symptoms; high risk) D (More symptoms; high risk) Recommended Therapy First Choice Second Choice Alternatives SAMA prn or SABA prn LAMA or LABA ICS + LABA or LAMA ICS + LABA and/or LAMA LAMA or LABA or SABA and SAMA LAMA and LABA LAMA and LABA ICS and LAMA or ICS + LABA and LAMA or ICS+LABA and PDE4I or LAMA and LABA or LAMA and PDE4I Theophylline SABA and/or SAMA Theophylline PDE4I SABA and/or SAMA Theophylline Acetylcysteine SABA and/or SAMA Theophylline See page 16 for enlarged view 10

11 Key Points Patients should be regularly assessed for symptom control and activity level Patients at high risk of exacerbations should receive treatment with long-acting bronchodilators, ICS, or both Oral agents should be reserved for patients who cannot administer or tolerate inhaled therapies Patient Scenario: TJ continued TJ reports using her albuterol MDI 3-4 times per day, depending on activity She further complains of a tremor and jittery feeling that lasts for about an hour after using her albuterol As a result, she has limited her activities to small chores around the house What would you recommend to optimize TJ s therapy during this visit? a. Start ipratropium 2 puffs INH every 6 hr b. Start formoterol 12 mcg INH every 12 hr c. Start tiotropium 18 mcg INH daily d. Start fluticasone 220 mcg INH every 12 hr Prevention of Complications Influenza infection can lead to complications in patients with COPD Exacerbations requiring hospitalization Viral pneumonia or secondary bacterial pneumonia Pneumococcal infection can lead to complications in patients with COPD Community-acquired pneumonia and invasive infections Pesek R et al. Allergy. 2011; 66:25-31 Immunization - Influenza Influenza vaccine recommended annually for all patients with COPD, regardless of age or disease severity 1,2 In COPD, immunization decreases Risk of developing influenza infection Risk of hospitalization, death 3 Patients can be immunized while on systemic and inhaled corticosteroids Poole PJ et al. Cochrane Database Syst Rev. 2006; Jan 25;(1): CD Pesek R et al. Allergy. 2011; 66: Immunization - Pneumococcal Pneumococcal polysaccharide vaccine recommended For all patients 65 years 1 For patients with COPD < 65 years (but > 2 years) AND FEV 1 < 40% of predicted 2 In COPD, effect of immunization on hospitalization or mortality is equivocal 3 Patients can be immunized while on systemic and inhaled corticosteroids Walters JA et al. Cochrane Database Syst Rev. 2010; Nov 10;(11):CD Pesek R et al. Allergy. 2011; 66:

12 Key Points Immunization is a low-risk intervention to prevent costly complications Pharmacists can assess patients for immunization status in various settings Community pharmacy Clinic Before discharge from hospital Patient Education In-person demonstration improves patient technique compared with written and oral instructions 1 Computer-based demonstration improves patient technique compared with usual care 2 Repeated, ongoing education improves adherence to inhalation therapy 3 1. Bosnic-Anticevich SZ et al. J Asthma. 2010; 47: Navarre M et al. Ann Pharmacother. 2007; 41: Takemura M. J Asthma. 2010; 47: Medication and Device Counseling Role of medications Rescue versus maintenance agents Expected effects, recognition of adverse effects Inhalation devices Metered-dose inhaler Dry-powder inhaler (DPI) Nebulizer Peak Inspiratory Flow (PIF) Maximum rate of inhalation (L/min) Depends on effort, airflow limitation, age Handheld device (In-Check DIAL) Measures 15 to 120 L/min Adapters to simulate device resistance Used by clinicians to assess PIF Used for patient education and feedback PIF and COPD Study of 53 COPD patients 1 Average age 73 years Varying disease severity PIF was linearly correlated with FEV 1 percent of predicted Patients with FEV 1 30% of predicted had a measured PIF of approximately 30 L/min Jarvis S et al. Age Ageing. 2007; 36: Optimal PIF for Devices MDI Desired PIF between 30 and 60 L/min Minimum PIF approximately 25 L/min DPI More variability among devices due to internal resistance Turbuhaler minimum PIF 60 L/min HandiHaler minimum PIF 20 L/min Diskus minimum PIF 30 L/min Nebulizer Independent of PIF rate 12

13 Metered-dose Inhalers Medication administered as aerosol with pressurized propellant CFC vs. HFA propellants Actuation independent of inhalation Large particles with high velocity More oropharyngeal deposition, less inspired Can use with spacer or holding chamber Can use with ventilator or tracheostomy CFC = chlorofluorocarbon HFA = hydrofluoroalkane Considerations - MDI Coordination of inhalation with actuation of inhaler Inhale slowly to minimize particle deposition in mouth Priming Before first use If not used for several days Shake before use Dry-powder Inhalers Medication administered as powder in capsule or blister that is punctured No propellant Actuation dependent on inspiration Adequate inspiratory flow necessary Cannot use with ventilator, tracheostomy Smaller particles with slower velocity Do not use with spacer Considerations - DPI Do not need to coordinate inhalation and actuation Inhale quickly to break up powder particles for inspiration No propellant no priming, no shaking Low inspiratory flow rates may have trouble triggering device Children, elderly, severe COPD Nebulizer Converts medication in solution or suspension to aerosol Pneumatic jet nebulizer uses compressed gas to aerosolize Ultrasonic nebulizer uses high-frequency ultrasonic waves to aerosolize Does not aerosolize suspensions well Delivery independent of inspiration Considerations - Nebulizers Effective for patients who lack coordination to use other inhalation devices Requires set up and cleaning Time intensive compared with other devices More expensive Not portable Can use with ventilator, tracheostomy 13

14 Patient Considerations Physical limitations Vision, tremor, arthritis Ability to understand multiple inhaler techniques MDI vs. DPI Patients with severe airflow obstruction (FEV 1 < 30% of predicted) Certain DPIs may not be effective Cost and insurance issues Key Points Teach back and observation are important during counseling Various communication methods can be used Education should be repeated at ongoing visits Consider patient factors when choosing inhalation devices 14

15 Patient Category A Combined Assessment Determine patient category based on spirometry, exacerbations and/or symptoms. Choose highest risk feature. B C D Description Spirometry Exacerbations in Last Year* Less symptoms; low risk More symptoms; low risk Less symptoms; high risk More symptoms; high risk FEV 1 50% of predicted FEV 1 50% of predicted FEV 1 < 50% of predicted FEV 1 < 50% of predicted CAT mmrc CCQ 0-1 < > 1 2 < > 1 *One or more exacerbations requiring hospitalization equals high risk. Effect of Smoking on Lung Function Decline Fletcher C et al. Br Med J. 1977; 1(6077): Reprinted with permission. 15

16 Future Inhaled Therapies Class Medication Device Status LAMA Glycopyrronium Breezhaler Approved by EMA LAMA/LABA Glycopyrronium/indacaterol Breezhaler Under review - EMA LAMA/LABA Umeclidinium/vilanterol Ellipta Under review - FDA ICS/LAMA/LABA MABA Fluticasone/umeclidinium/ vilanterol Ellipta Phase I trials , LAS190792, AZD2115 Various Phase I and II trials EMA = European Medicines Agency FDA = Food and Drug Administration MABA = muscarinic antagonist β agonist Recommended Therapy Patient Category First Choice Second Choice Alternatives A (Less symptoms; low risk) SAMA prn or SABA prn LAMA or LABA or SABA and SAMA Theophylline B (More symptoms; low risk) LAMA or LABA LAMA and LABA SABA and/or SAMA Theophylline C (Less symptoms; high risk) ICS + LABA or LAMA LAMA and LABA PDE4I SABA and/or SAMA Theophylline D (More symptoms; high risk) ICS + LABA and/or LAMA ICS and LAMA or ICS + LABA and LAMA or ICS+LABA and PDE4I or LAMA and LABA or LAMA and PDE4I Acetylcysteine SABA and/or SAMA Theophylline 16

17 Chronic Obstructive Pulmonary Disease: The Pharmacist s Role in Ongoing Patient Education and Management SELECTED REFERENCES AND USEFUL RESOURCES 1. Anon. Treatment guidelines: drugs for asthma and COPD. The Medical Letter. 2013; 11(132): for%20Asthma%20and%20COPD&i=132 (accessed 2013 Sept 9). 2. Bosnic-Anticevich SZ, Sinha H, So S et al. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. J Asthma. 2010; 47: Buddiga P. Use of metered dose inhalers, spacers and nebulizers. Updated Jun 3, (accessed 2013 Sept 16). 4. Bynum A, Hopkins D, Thomas A et al. The effect of telepharmacy counseling on metered-dose inhaler technique among adolescents with asthma in rural Arkansas. Telemed J E Health. 2001; 7: Centers for Disease Control and Prevention (CDC). Chronic obstructive pulmonary disease among adults United States, MMWR Morb Mortal Wkly Rep. 2012; 61: Centers for Disease Control and Prevention (CDC). National Center for Health E-Stat. Vaccination coverage estimates from the National Health Interview Survey: United States, (accessed 2013 Sept 9). 7. Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices (ACIP). (accessed 2013 Sept 9). 8. Fletcher C, Peto R. The natural history of chronic airflow obstruction. Br Med J. 1977; 1(6077): Ford ES, Croft JB, Mannino DM et al. COPD Surveillance-United States, Chest; 144: Giraud V, Allaert FA, Roche N. Inhaler technique and asthma: feasibility and acceptability of training by pharmacists. Respir Med. 2011; 105: Global Initiative for Chronic Obstructive Lung Disease, Inc. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (updated 2013). (accessed 2013 Sept 9). 12. Inhaler Error Steering Committee, Price D, Bosnic-Anticevich S et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med. 2013; 107: Jackevicius CA, Chapman KR. Inhaler education for hospital-based pharmacists: how much is required? Can Respir J. 1999; 6: Jarvis S, Ind PW, Shiner RJ. Inhaled therapy in elderly COPD patients: time for re-evaluation? Age Ageing. 2007; 36: Make BP, Dutro MP, Paulose-Ram R et al. Undertreatment of COPD: a retrospective analysis of US managed care and Medicare patients. Int J Chron Obstruct Pulmon Dis. 2012; 7:

18 Chronic Obstructive Pulmonary Disease: The Pharmacist s Role in Ongoing Patient Education and Management 16. Mäkelä MJ, Backer V, Hedegaard M et al. Adherence to inhaled therapies, health outcomes and costs in patients with asthma and COPD. Respir Med May 2 [Epub ahead of print]. 17. Navarre M, Patel H, Johnson CE et al. Influence of an interactive computer-based inhaler technique tutorial on patient knowledge and inhaler technique. Ann Pharmacother. 2007; 41: Pesek R, Lockey R. Vaccination of adults with asthma and COPD. Allergy. 2011; 66: Poole PJ, Chacko E, Wood-Baker RW et al. Influenza vaccine for patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev Jan 25;(1):CD Savage I, Goodyer L. Providing information on metered dose inhaler technique: is multimedia as effective as print? Fam Pract. 2003; 20: Takemura M. Repeated instruction on inhalation technique improves adherence to the therapeutic regimen in asthma. J Asthma. 2010; 47: United States Department of Health and Human Services. HealthyPeople.gov: respiratory diseases. (accessed 2013 Sept 9). 23. U.S. Food and Drug Administration. FDA: FDA approved drug products. (accessed 2013 Sept 9). 24. Walters JA, Smith S, Poole P et al. Injectable vaccines for preventing pneumococcal infection in patients with chronic obstructive pulmonary disease. Cochrane Database Syst Rev Nov 10;(11):CD

19 Chronic Obstructive Pulmonary Disease: The Pharmacist s Role in Ongoing Patient Education and Management SELF-ASSESSMENT QUESTIONS 1. You have been asked to establish the role of the pharmacist in a pulmonary clinic and are developing a protocol for assessing symptom control in patients with chronic obstructive pulmonary disease (COPD). Which of the following would be the most appropriate method for assessing symptom control in this population? a. Ask patients to record use of rescue medication, such as albuterol. b. Ask patients to complete a COPD questionnaire, such as the COPD Assessment Test (CAT). c. Ask patients to record daily peak flow measurements at home. d. Review patient charts for comorbid diseases that could worsen symptoms. 2. TM is a 72-year-old woman who was diagnosed with COPD 8 years ago. She had pulmonary function tests last year which showed an FEV 1 that was 53% of predicted. She has had 2 exacerbations in the last year, one which required a 4-day admission to the hospital. During her regular primary care visit, she completes the CAT questionnaire and has a score of 8. Which patient category as defined by Global Initiative for COPD (GOLD) best describes TM? a. GOLD patient category A. b. GOLD patient category B. c. GOLD patient category C. d. GOLD patient category D. 3. You are seeing a 59-year-old patient in clinic who has been recently diagnosed with COPD. He smoked cigarettes for 40 years (60 pack-year history) but has cut back to only half a pack per day since his diagnosis. He has an FEV 1 that is 63% of predicted and currently uses albuterol metereddose inhaler (MDI) as needed for shortness of breath. The patient asks for your opinion about his disease. What recommendations would you make to slow disease progression? a. Stop smoking entirely. b. Initiate an inhaled corticosteroid. c. Initiate a long-acting bronchodilator. d. Nothing since COPD is a progressive disease. 4. When demonstrating the use of a dry-powder inhaler (DPI), the patient should be instructed to a. Inhale slowly after actuation. b. Inhale quickly. c. Use with a spacer or holding chamber. d. Shake well before each use. 19

20 Chronic Obstructive Pulmonary Disease: The Pharmacist s Role in Ongoing Patient Education and Management 5. DH is an 88-year-old man with COPD and severe cognitive impairment due to dementia. He lives in a nursing home and has help with all of his medications and activities of daily living. He is prescribed albuterol MDI 2 puffs by inhalation every 4 hours as needed for shortness of breath and fluticasone/salmeterol DPI 250 mcg/50 mcg by inhalation every 12 hours. He is unable to follow instructions regarding inhaler technique and cannot coordinate the inhaler with inhalation or inhale appropriately with coaching. Which of the following recommendations would be most appropriate for DH at this time? a. Change inhalers to oral theophylline. b. Add tiotropium DPI 18 mcg by inhalation daily. c. Change DPI inhalers to budesonide/formoterol MDI. d. Convert inhalers to nebulized formulations. Answers 1. b 2. c 3. a 4. b 5. d 20

21 Chronic Obstructive Pulmonary Disease: The Pharmacist s Role in Ongoing Patient Education and Management APPENDIX Appendix: Commonly Used Medications for Chronic Obstructive Pulmonary Disease Short Acting Bronchodilators Short acting β 2 agonists Short acting anticholinergics Long Acting Bronchodilators Long acting β 2 agonists Long acting anticholinergics Inhaled Corticosteroids Combination Inhalers Other Medications Active Ingredient Dosage Form; Route Strength Usual Frequency Proprietary Name ALBUTEROL SULFATE AEROSOL, METERED; INHALATION EQ 0.09MG BASE/INH Four to six times a day as needed PROVENTIL HFA; VENTOLIN HFA; PROAIR HFA ALBUTEROL SULFATE SOLUTION; INHALATION EQ 0.021% BASE; EQ 0.042% BASE; EQ Four to six times a day as ACCUNEB; GENERIC 0.083% BASE; EQ 0.5% BASE needed ALBUTEROL SULFATE; IPRATROPIUM BROMIDE SPRAY, METERED; INHALATION EQ 0.1 MG BASE/INH; 0.02 MG/INH Four to six times a day as COMBIVENT RESPIMAT needed ALBUTEROL SULFATE; IPRATROPIUM BROMIDE SOLUTION; INHALATION EQ 0.083% BASE; 0.017% Four to six times a day as DUONEB; GENERIC needed LEVALBUTEROL HYDROCHLORIDE SOLUTION; INHALATION EQ % BASE; EQ 0.021% BASE; EQ Three to four times as day as XOPENEX; GENERIC 0.25% BASE; EQ 0.042% BASE needed LEVALBUTEROL TARTRATE AEROSOL, METERED; INHALATION EQ 0.045MG BASE/INH Three to four times as day as XOPENEX HFA needed IPRATROPIUM BROMIDE AEROSOL, METERED; INHALATION MG/INH Four times a day as needed ATROVENT HFA IPRATROPIUM BROMIDE SOLUTION; INHALATION 0.02% Four times a day as needed IPRATROPIUM BROMIDE; GENERIC ARFORMOTEROL TARTRATE SOLUTION; INHALATION EQ MG BASE/2 ML Twice daily BROVANA FORMOTEROL FUMARATE POWDER; INHALATION MG/INH Twice daily FORADIL FORMOTEROL FUMARATE SOLUTION; INHALATION 0.02 MG/2 ML Twice daily PERFOROMIST INDACATEROL MALEATE POWDER; INHALATION EQ 75 MCG BASE Once daily ARCAPTA NEOHALER SALMETEROL XINAFOATE POWDER; INHALATION EQ 0.05 MG BASE/INH Twice daily SEREVENT ACLIDINIUM BROMIDE POWDER, METERED; INHALATION MG/INH Twice daily TUDORZA PRESSAIR TIOTROPIUM BROMIDE MONOHYDRATE POWDER; INHALATION EQ MG BASE/INH Once daily SPIRIVA BECLOMETHASONE DIPROPIONATE AEROSOL, METERED; INHALATION 0.04 MG/INH; 0.08 MG/INH Twice daily QVAR 40; QVAR 80 BUDESONIDE POWDER, METERED; INHALATION 0.08 MG/INH; 0.16 MG/INH Twice daily PULMICORT FLEXHALER BUDESONIDE SUSPENSION; INHALATION 0.25 MG/2 ML; 0.5 MG/2 ML; 1 MG/2 ML Once or twice daily PULMICORT RESPULES; GENERIC FLUNISOLIDE AEROSOL, METERED; INHALATION EQ 78 MG BASE/INH; 0.25 MG/INH Twice daily AEROSPAN HFA; AEROBID FLUTICASONE PROPIONATE AEROSOL, METERED; INHALATION MG/INH; 0.11 MG/INH; Twice daily FLOVENT HFA 0.22 MG/INH MOMETASONE FUROATE POWDER; INHALATION 0.11 MG/INH; 0.22 MG/INH Twice daily ASMANEX TWISTHALER BUDESONIDE; FORMOTEROL FUMARATE DIHYDRATE FLUTICASONE FUROATE; VILANTEROL TRIFENATATE FLUTICASONE PROPIONATE; SALMETEROL XINAFOATE FLUTICASONE PROPIONATE; SALMETEROL XINAFOATE MOMETASONE FUROATE; FORMOTEROL FUMARATE AEROSOL, METERED; INHALATION 0.08 MG/INH; MG/INH; Twice daily SYMBICORT 0.16 MG/INH; MG/INH POWDER; INHALATION 0.1 MG/INH; EQ MG BASE/INH Once daily BREO ELLIPTA POWDER; INHALATION AEROSOL, METERED; INHALATION AEROSOL, METERED; INHALATION 0.1 MG/INH; EQ 0.05 MG BASE/INH; 0.25 MG/INH; EQ 0.05 MG BASE/INH; 0.5 MG/INH; EQ 0.05 MG BASE/INH MG/INH; EQ MG BASE/INH; MG/INH; EQ MG BASE/INH; 0.23MG/INH; EQ MG BASE/INH MG/INH; 0.1 MG/INH; MG/INH; 0.2MG/INH Twice daily ADVAIR DISKUS 100/50; ADVAIR DISKUS 250/50; ADVAIR DISKUS 500/50 Twice daily Twice daily ADVAIR HFA ROFLUMILAST TABLET; ORAL 500 MCG Once daily DALIRESP THEOPHYLLINE CAPSULE, EXTENDED RELEASE; ORAL 100 MG; 200 MG; 300 MG; 400 MG Once daily THEO 24 THEOPHYLLINE ELIXIR; ORAL and SOLUTION; ORAL 80 MG/15 ML Three to four times a day ELIXOPHYLLIN; GENERIC THEOPHYLLINE TABLET, EXTENDED RELEASE; ORAL 100 MG; 200 MG; 300 MG; 450 MG Once or twice daily THEOPHYLLINE; GENERIC THEOPHYLLINE TABLET, EXTENDED RELEASE; ORAL 100 MG; 200 MG; 300 MG; 400 MG; Once or twice daily THEOCHRON 600 MG THEOPHYLLINE TABLET; ORAL 125 MG; 250 MG Three to four times a day THEOLAIR DULERA Anon. Treatment guidelines: drugs for asthma and COPD. The Medical Letter. 2013; 11(132): or%20asthma%20and%20copd&i=132 (accessed 2013 Sept 9). U.S. Food and Drug Administration. FDA: FDA approved drug products. (accessed 2013 Sept 9). 21

22 Chronic Obstructive Pulmonary Disease: The Pharmacist s Role in Ongoing Patient Education and Management Instructions for Processing CE Credit with Enrollment Code Pharmacistss and Technicians: All ACPE accredited activities which are processed on the elearning site will be reported directly to CPE Monitor. To claim pharmacy credit, you must have your NABP e-profile ID, birth month, and birth day. If you do not have an NABP e-profile ID, go to for information and application. Please follow the instructions below to process your CPE credit for this activity. 1. The ASHP elearning site allows participants to obtain statements of continuing education conveniently and immediately using any computer with an internet connection. Type the following link into your web browser to access the e-learning site: 2. If you already have an account registered with ASHP, log in using your username and password. If you have not logged in to any of the ASHP sites before and/or are not a member of ASHP, you will need to set up an account. Click on the Registerr link and follow the registration instructions. 3. Once logged in to the site, enter the enrollment code forr this activity in the field provided and click Redeem. Note: The Enrollment Code was announced at the end of the live activity. Please record the Enrollment Code in the grid below for your records. 4. The title of this activity should now appear in a pop-up box on your screen. Click on the Go button or the activity title. 5. Completee all required elements. A green You can now claim your credit. should appear as each required element is completed. 6. Available credit(s) will appear beneath the completed required activities. Look for your profession in the list of available credits and click the appropriate Claim button. You might have to click to see more credit options if you don t see your profession listed. CPE Credit for Pharmacists s and Technicians: To claim continuing pharmacy education (CPE) credit, you will need to enter your NABP e-profile ID, birth month, and birth day. Once you have entered this information the first time, it will auto fill in the future. Please note: All CPE credit processed on the elearning site will be reported directly to CPE Monitor. 7. Review the information for the credit you are claiming. Iff all information appears to be correct, check the box at the bottom and click Claim. You will see a message if there are any problems claiming your credit. 8. After successfully claiming credit, you may print your statement of credit by clicking on Print. If you require a reprint of a statement of credit, you can return here at any time to print a duplicate. Please note thatt for CPE credit, printed statements may not be necessary because your credit will be reported directly to CPE Monitor. Date of Activity - - / - - / - - Activity Title Chronic Obstructive Pulmonaryy Disease: The Pharmacist s Role in Ongoing Patient Education and Management Enrollment Code _ Credit Hours 1.0 NEED HELP? Co ontact elearning@ashp.org. 22

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