COPD RESOURCE PACK Section 5. Drug Treatment & Inhalers in Stable COPD

Transcription

1 COPD RESOURCE PACK Section 5 Drug Treatment & Inhalers in Stable COPD In this section: 1. Links to Fife Formulary 2. Pharmacological Management of Stable COPD 3. How to use a Metered Dose Inhaler 4. How to use the Metered Dose Inhaler & Spacer [Aerochamber] 5. How to use a Dry Powder Inhaler 6. How to use the Relvar Ellipta Inhaler 7. How to use the Genuair Inhaler 8. Spacers and matching devices COPD Resource Pack: Section 5: Drug Treatment & Inhalers in Stable COPD Version 3 Last Updated: December 2014

2 1. LINKS TO FIFE FORMULARY 2. PHARMACOLOGICAL MANAGEMENT OF STABLE COPD Start therapy at the step most appropriate to severity of disease. The choice of drug(s) should take into account symptomatic response, patient preference, ability to use a particular device, the drug s potential to reduce exacerbations, side effects, and cost. Each step should be started on an 8 week trial basis and withdrawn if ineffective. The effectiveness of COPD treatment should be assessed by looking for improvement in patient symptoms, activities of daily living, exercise capacity and speed of symptom relief (short-acting bronchodilator only), rather than based on changes in lung function. Reference should be made to the Fife Formulary (see link above) for local guidance on treatment options for each drug group. Helpful questions to gauge if treatment is effective Has the treatment made a difference to the patient? Is their breathing easier in any way? Can they do the same things now that they couldn t do before, or do the same things but faster? Can they do the same things as before but are now less breathless when they do them? Has their sleep improved? Assessment tools (e.g. COPD Assessment Test (CAT ) Score) can be used to quantify subjective improvement. Jones PW, Bellamy d, Crocket AWB et al (2001). Assessing Treatment outcomes in COPD. Synergy Medical Education.London Page 2 of 12

3 Inhaled Therapy Breathlessness and/ or exercise limitation SABA or SAMA as required* Exacerbations or persistent FEV 1 >= 50% breathlessness FEV 1 < 50% LABA LAMA** In preference to regular SAMA 4xdaily LABA + ICS (Combination inhaler) Consider LABA + LAMA if ICS declined or not tolerated LAMA** In preference to regular SAMA 4xdaily LABA + LAMA** In preference to regular SAMA 4xdaily Persistent exacerbations or breathlessness LAMA + LABA+ICS (combination inhaler) Offer therapy Consider therapy * Short-acting B 2 agonist (SABA) as required may continue all stages ** Discontinue Short-acting muscarinic antagonist (SAMA) National Institute for Clinical Excellence (NICE). Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Update guideline. June Quick Reference Guide. Inhaled Bronchodilators Treat breathlessness and exercise limitation initially with short-acting bronchodilators (B 2 agonists or antimuscarinics) as needed. Patients who remain breathless or have exacerbations despite using short-acting bronchodilators as required (e.g. four times daily) can be offered a long-acting B 2 agonist or once-daily long-acting muscarinic antagonist. A long-acting muscarinic antagonist can be added to combination therapy (long-acting B 2 agonist & corticosteroid) where the patient remains breathless or has exacerbations. It can also be used in combination with a long-acting B 2 agonist where an inhaled corticosteroid cannot be tolerated. Page 3 of 12

4 Inhaled Corticosteroids Reversibility testing with oral corticosteroids is not required to identify patients who may benefit from inhaled corticosteroid therapy. Consider inhaled corticosteroids where FEV 1 <50% predicted, who have 2 or more exacerbations needing treatment with antibiotics or oral corticosteroids a year. Bear in mind high doses of inhaled corticosteroids have been associated with pneumonia and other significant side effects, particularly in older patients with COPD. Ensure preparations licensed for use in COPD are used Oral Therapy Corticosteroids Maintenance use of oral corticosteroid therapy in COPD is not recommended. However, a few patients with advanced COPD may need maintenance oral corticosteroids if oral corticosteroids cannot be withdrawn after an exacerbation. In those cases, keep the dose as low as possible, monitor patients for osteoporosis and offer prophylaxis (appendix 6A of Fife Formulary) Theophylline Prescribe only after trials of short- and long-acting bronchodilators or for patients who cannot use inhalers. Remember the need to monitor plasma levels and consider drug interactions. Can be used in combination with B 2 agonists and muscarinic antagonists. Particular caution is needed in elderly patients because of pharmacokinetics, comorbidities and interactions with other medication. Reduce dose if interacting drugs (e.g. macrolide or quinolone antibiotics) are prescribed. Mucolytic Therapy Not for routine use in exacerbation prevention. Consider where there is a chronic productive cough and only continue if symptoms improve following a trial of four weeks. Page 4 of 12

5 Current Fife Formulary choices (correct as at December 2014) Short-acting Bronchodilator (SABA) Long-acting Bronchodilator (LABA) Inhaled Corticosteroid Corticosteroids Metered Dose Inhaler (MDI) Salbutamol Salmeterol 1 st Line choice Fostair Beclometasone (Clenil Modulite, Qvar ) 2 nd Line choice Budesonide Dry Powder Inhaler (DPI) Easyhaler Salbutamol Easyhaler Formoterol 1 st Line choice 2 nd Line choice Relvar Ellipta Symibort (fluticasone Turbohaler furoate + (budesonide vilanterol + Easyhaler Beclometasone formoterol) Easyhaler Budesonide Short-acting antimuscarinic (SAMA) Long-acting antimuscarinic (LAMA) 1 st line choice 2 nd line choice Ipratropium Tiotropium (Spiriva Handihaler ) 2 nd line choice Aclidinium (Eklira Genuair ) Twice daily; suitable in patients who have inadequate 24 hour cover with tiptropium, or who find the Handihaler device difficult to use. Delivery Systems Inhalers Most patients, whatever their age, can learn how to use an inhaler unless they have significant cognitive impairment. Hand-held devices are usually best, with a spacer if appropriate. If a patient cannot use a particular device, try another. Teach technique before prescribing an inhaler, and check regularly. Spacers Ensure the spacer is compatible with the patient s inhaler. Patients should make single actuations of the inhaler into the spacer, and inhale as soon as possible, repeating as needed. Tidal breathing is as effective as single breaths. Clean using water and washing up liquid and allow to air dry. Do not clean the spacer any more often than monthly, otherwise the static built up will interfere with the performance of the device. Page 5 of 12

6 Nebulisers Only consider a nebuliser for patients with distressing or disabling breathlessness despite maximal therapy with inhalers. Assess the patient and/or carer s ability to use the nebuliser before prescribing, and consider whether access is available to equipment, servicing, advice and support. Refer to the MCN Nebuliser Guideline available on the Respiratory MCN section of the NHS Fife website. : 3. HOW TO USE A METERED DOSE INHALER Click on the following link to view a demo provided by Asthma UK: Metered dose inhalers (MDIs) The metered dose inhaler contains the medicine in aerosol form. When you press the canister down a dose of the medicine is released as an aerosol at high speed. To use an MDI you have to press down on the canister just after you have started breathing in, and so it needs some co-ordination. You should breathe the aerosol in at a slow and gentle rate. This slows down the aerosol so it doesn t coat the back of your throat and allows more of the medicine to get into your lungs. But, if you breathe in too slowly the medicine will stay in your mouth or come out down your nose and won t get into your lungs where it s needed. It s tricky to get it right, so the best way to use a metered dose inhaler is with a spacer. 32 How to use an MDI 1. Remove mouthpiece cover and shake inhaler. 2. Breathe out gently as far as is comfortable. 3. Put the mouthpiece into your mouth between your teeth and close your lips around it. 4. As you begin to breathe in, press the canister down and continue to inhale slowly and deeply (eg deep inward sigh ). 5. Remove the MDI from your mouth and hold your breath for 10 seconds, or as long as is comfortable. 6. For a second dose, wait for approximately 30 seconds before repeating steps 1 5. Replace the mouthpiece cover after use. Page 6 of 12

7 4. HOW TO USE A METERED DOSE INHALER AND SPACER: AEROCHAMBER DEVICE 1. Remove cap from inhaler check mouthpiece for any objects, which could be inhaled. 2. Relax. 3. Shake the inhaler and insert into the back of the aerochamber. 4. Place the mouthpiece of the aerochamber in the mouth. 5. Press the inhaler ONCE to release a dose of the drug. 6. Breathe in and out slowly and gently 5 TIMES (Tidal Breathing) 7. If you hear a whistling sound you are breathing TOO DEEPLY. 8. Remove the mouthpiece from mouth and relax. 9. Wait 30 seconds 1 minute and then repeat steps 2-8 for each puff prescribed. [James Paget University Hospitals NHS Foundation Trust, Respiratory Nursing Service, How to use your aerochamber, March 2009, Version 1] 5. HOW TO USE A DRY POWDER INHALER Dry Powder Inhalers The medicine in dry powder inhalers is stored in a reservoir or as individual doses. When you breathe in through the mouthpiece the force of your breath releases the medicine, so your breath has to be fast and deep. The turbulence created in the inhaler by your breath will break the medicine down into small particles so it can get down into your airways where it s needed. Different dry powder inhalers need different amounts of effort so they need to be carefully selected by the doctor or nurse to suit you. How to use a DPI 1. Unscrew and lift off the white mouthpiece cover. 2. Hold the Turbohaler upright and twist the grip (at the base) forwards and backwards as far as it will go. You should hear a click. 3. Breathe out gently as far as is possible. Put the mouthpiece between your teeth and close your lips around it. Do not block the air holes on top. 4. Breathe in quickly and deeply. Even when a full dose is taken there may not be any taste. 5. Remove from mouth and breathe out slowly. 6. For a second dose repeat steps 1 5. Replace the mouthpiece cover after use. When a red line appears at the top of the window on the Turbohaler, there are approximately 20 doses left. Page 7 of 12

8 6. HOW TO USE THE RELVAR ELLIPTA INHALER If you open and close the cover without inhaling the medicine, you will lose the dose. The lost dose will be securely held inside the inhaler, but it will no longer be available. It is not possible to accidentally take extra medicine or a double dose in one inhalation. 1. Wait to open the cover until you are ready to take your dose. Do not shake the inhaler. Slide the cover down until you hear a click Your medicine is now ready to be inhaled. The dose counter counts down by 1 to confirm. If the dose counter does not count down as you hear the click, the inhaler will not deliver medicine. Take it back to your pharmacist for advice. 2. While holding the inhaler away from your mouth, breathe out as far as is comfortable Do not breathe out into the inhaler. Put the mouthpiece between your lips, and close your lips firmly around it. Do not block the air vent with your fingers. Take one long, steady, deep breath in. Hold this for as long as possible (about 3-4 seconds). Remove the inhaler from your mouth. Breathe out slowly and gently. You may not be able to taste or feel the medicine, even when you are using the inhaler correctly. 3. Close the inhaler and rinse your mouth if possible Rinse your mouth with water after you have used the inhaler. This will make it less likely that you will develop a sore mouth or throat as side effects. If you want to clean the mouthpiece, use a dry tissue, before you close the cover. Slide the cover upwards as far as it will go, to cover the mouthpiece. Package leaflet: Information for the user Relvar Ellipta 92 micrograms/22 micrograms inhalation powder, pre-dispensed Relvar Ellipta 184 micrograms/22 micrograms inhalation powder, pre-dispensed Patient Information Leaflet (May 2014) Page 8 of 12

9 7. HOW TO USE THE GENUAIR INHALER Becoming familiar with Eklira Genuair: Remove the Genuair inhaler from the pouch and become familiar with its components. How to Use Eklira Genuair Summary To use your Genuair inhaler there are 2 steps you need to perform after removing the cap: Step 1: Press and RELEASE the green button and breathe out completely, away from the inhaler. Step 2: Place your lips tightly around the mouthpiece and inhale STRONGLY and DEEPLY through the inhaler. After inhalation, remember to replace the protective cap. Getting Started Before first use, tear the sealed pouch along the notch and remove the Genuair inhaler. When you are about to take your dose of medicine, remove the protective cap by lightly squeezing the arrows marked on each side and pulling outwards (see image 1). Look to see that nothing is blocking the mouthpiece. IMAGE 1 Hold the Genuair inhaler horizontally with the mouthpiece towards you and the green button facing straight up (see image 2). Hold with the green button facing straight up. DO NOT TILT. IMAGE 2 Page 9 of 12

10 STEP 1: PRESS the green button all the way down and then RELEASE it (see images 3 and 4) DO NOT CONTINUE TO HOLD THE GREEN BUTTON DOWN. PRESS the green button all the way down RELEASE the green button IMAGE 3 IMAGE 4 Stop and Check: Make sure dose is ready for inhalation Make sure the coloured control window has changed to green (see image 5). The green control window confirms that your medicine is ready for inhalation. Ready to use GREEN Ready to use IMAGE 5 IF THE COLOURED CONTROL WINDOW STAYS RED, PLEASE REPEAT PRESS AND RELEASE ACTIONS (SEE STEP 1). Before bringing the inhaler to your mouth, breathe out completely. Do not breathe out into the inhaler. STEP 2: Put your lips tightly around the mouthpiece of the Genuair inhaler and inhale STRONGLY and DEEPLY through the mouthpiece (see image 6). - This strong, deep breath pulls the medicine through the inhaler into your lungs. ATTENTION: DO NOT HOLD THE GREEN BUTTON DOWN WHILE YOU ARE INHALING. CORRECT INCORRECT IMAGE 6 Page 10 of 12

11 While you breathe in you will hear a CLICK which signals that you are using the Genuair inhaler correctly. Keep breathing in even after you have heard the inhaler CLICK to be sure you get the full dose. Remove the Genuair inhaler from your mouth and hold your breath for as long as is comfortable, then breathe out slowly through your nose. Note: Some patients may experience a mild sweet or slightly bitter taste, depending on the patient, when inhaling the medicine. Do not take an extra dose if you do not taste anything after inhaling. Inhaled correctly Stop and Check: Make sure you have inhaled correctly Make sure the control window has turned to red (see image 7). This confirms that you have inhaled your full dose correctly. RED IF THE COLOURED CONTROL WINDOW IS STILL GREEN, PLEASE REPEAT INHALING STRONGLY AND DEEPLY THROUGH THE MOUTHPIECE (SEE STEP 2). IMAGE 7 If the window still does not change to red, you may have forgotten to release the green button before inhaling or may not have inhaled correctly. If that happens, try again. Make sure you have RELEASED the green button and take a STRONG deep breath in through the mouthpiece. Note: If you are unable to inhale correctly after several attempts, consult your doctor. Once the window has turned red, replace the protective cap by pressing it back onto the mouthpiece (see image 8). When should you get a new Genuair inhaler? The Genuair inhaler is equipped with a dose indicator to show you approximately how many doses are left in the inhaler. The dose indicator moves down slowly, displaying intervals of 10 (60, 50, 40, 30, 20, 10, 0) (see image A). Every Genuair inhaler will deliver at least 60 doses. IMAGE 8 Dose indicator goes down by intervals of 10: 60, 50, 40, 30, 20, 10, 0. Dose indicator Red Striped Band When a red striped band appears in the dose indicator (see image A), this means you are nearing your last dose and you should obtain a new Genuair inhaler. IMAGE A Page 11 of 12

12 Note: If your Genuair inhaler appears to be damaged or if you lose the cap, your inhaler should be replaced. You DO NOT NEED to clean your Genuair inhaler. However, if you wish to clean it you should do so by wiping the outside of the mouthpiece with a dry tissue or paper towel. NEVER use water to clean the Genuair inhaler, as this may damage your medicine. How do you know that your Genuair inhaler is empty? When 0 (zero) appears in the middle of the dose indicator, you should continue using any doses remaining in the Genuair inhaler. When the last dose has been prepared for inhalation, the green button will not return to its full upper position, but will be locked in a middle position (see image B). Even though the green button is locked, your last dose may still be inhaled. After that, the Genuair inhaler cannot be used again and you should start using a new Genuair inhaler. Locked Patient Information Leaflet (May 2014) IMAGE B 8. SPACERS AND MATCHING DEVICES SPACER Aerochamber Plus Volumatic MATCHING DEVICE Fits all MDI s Clenil Modultie Flixotide Seretide Serevent Ventolin Page 12 of 12