Take My Breath Away COPD Update. Take My Breath Away COPD Update 4/16/16. Juliann Horne, PharmD, PhC, BCACP

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1 Take My Breath Away COPD Update Juliann Horne, PharmD, PhC, BCACP April 16, 2016 Take My Breath Away COPD Update Juliann Horne, PharmD, PhC, BCACP April 16,

2 Conflicts of Interest Nothing to disclose 2

3 Learning ObjecLves Pharmacists Describe signs and symptoms and classificalon of chronic obstruclve pulmonary disease (COPD). Explain the role of pharmacotherapy for COPD. Compare and contrast recently approved pharmacotherapeulc agents and inhaler devices for the treatment of COPD. Learning ObjecLves Technicians List signs and symptoms of COPD. List treatments and inhaler devices for COPD. Explain the role of pharmacotherapy for COPD. Explain appropriate use of recently approved inhaler devices. 3

4 Background Diagnosis & Assessment Treatment Outline o Non- pharmacological o New evidence in pharmacotherapy Devices & AdministraLon 4

5 Epidemiology COPD GOLD Guidelines rd leading cause of death in the US 12.7 million US adults eslmated to have COPD (2011) o Largely undereslmated o ~24 million U.S. adults have evidence of impaired lung funclon o Slightly more common in women than men About 80% of cases due to cigare1e smoking Financial burden (US) o EsLmated cost: $49.9 billion (direct and indirect) 5

6 COPD Symptoms (Indicators to Consider a COPD Diagnosis) Diagnosis and Assessment Over 40 years of age (generally) Dyspnea Progressive Persistent Worse with exercise Chronic cough Chronic sputum produclon History of exposure to risk factors Family history of COPD Not diagnoslc but increases probability of COPD Perform spirometry in palents > 40 with any other indicators 6

7 Spirometric Assessment Post- bronchodilator FEV 1 % predicted classifies severity of airflow limitalon In palents with FEV 1 :FVC < 0.70 (70%): GOLD Classifica?on Severity FEV 1 (% predicted) Exacerba?ons per year GOLD 1 Mild FEV 1 80% predicted? GOLD 2 Moderate FEV % predicted GOLD 3 Severe FEV % predicted GOLD 4 Very Severe FEV 1 < 30% predicted

8 Combined Assessment of COPD Symptoms Risk FEV 1 ExacerbaLon history 8

9 PaLent Case Charlie is a 58 y/o female with COPD and diabetes. Shortness of breath when hurrying or walking uphill. Discharged from hospital 3 weeks ago for an exacerbalon. CAT = 8. Spirometry: FEV 1 68% of predicted. In which GOLD Combined Assessment PaLent Group does she belong? C A D B Asthma- COPD Overlap Syndrome (ACOS) Feature Asthma COPD Age of Onset Younger than 20 Older than 40 Panern of Symptoms Variable Triggers Worse at night or early AM DrasLc response to meds Good and bad days but symptoms despite meds Chronic cough, before dyspnea Lung FuncLon Variable airflow limitalon Persistent airflow limitalon FEV 1 /FVC < 0.7 Past/Family History Time Course Previous diagnosis or family history of asthma. No worsening of symptoms over Lme Previous diagnosis of chronic bronchils or emphysema Exposure to risk factor Symptoms slowly progress over Lme Chest X- ray Normal HyperinflaLon 9

10 Asthma- COPD Overlap Syndrome (ACOS) Treatment 10

11 Treatment Goals Reduce Symptoms Improve exercise tolerance Improve lung funclon (FEV 1 ) Improve quality of life and health status Reduce Risk Fewer exacerbalons Less disease progression Reduced mortality PaLent Case Maverick is a 63 y/o male with a 30 pack- year smoking history (quit 10 years ago), past medical history significant for hypertension and COPD. VaccinaLon history: o Influenza October 2015 o Tetanus 2012 o Zoster 2012 For which vaccines will he be due within the next 3 years? 11

12 Non- Pharmacologic/ProphylacLc Therapy Smoking cessa?on* Oxygen* Annual influenza vaccinalon Pneumococcal vaccinalon o PPSV23 for all COPD palents o PCV13 for all palents 65 or older Pulmonary rehabilitalon (for COPD group B- D) o Exercise, nutrilon, educalon, smoking cessalon, behavioral health *Mortality benefit 12

13 COPD Risk and Smoking CessaLon PaLent Case Maverick is a 63 y/o male with a 30 pack- year smoking history (quit 10 years ago), past medical history significant for hypertension and COPD. VaccinaLon history: o Influenza October 2015 o Tetanus 2012 o Zoster 2012 For which vaccines will he be due within the next 3 years? o Annual influenza o Pneumovax now o Prevnar at 65 o No Pneumovax 2 nd dose unll 68 (5 years aser first dose) BMJ. 1977;1:

14 Pharmacologic Therapy Overview LABA/LAMA Combo Controversial Role of ICS Treatment Goals Role of Pharmacotherapy Reduce Symptoms Improve exercise tolerance Improve lung func?on (FEV 1 ) Improve quality of life and health status Reduce Risk Fewer exacerba?ons Less disease progression Reduced mortality 14

15 Pharmacologic Treatment Principles Inhaled Treatments for COPD Inhaled treatment preferred Bronchodilators Inhaled corlcosteroids (ICS) Long- ac?ng bronchodilators preferred (LABA, LAMA) Consider combina?on of mechanisms Beta 2 - agonists AnLcholinergics Not to be used alone Avoid cor?costeroid monotherapy Short- aclng (SABA) Short- aclng (SAMA) Tailor device based on palent characterislcs Long- aclng (LABA) Long- aclng (LAMA) 15

16 COPD Drugs Approved Since 2013 Drug Class Date U?bron Neohaler (indacaterol + glycopyrrolate) LABA/LAMA Oct 2015 S?olto Respimat (Lotropium + olodaterol) LABA/LAMA May 2015 ProAir RespiClick (albuterol) SABA Apr 2015 Striverdi Respimat (olodaterol) LABA July 2014 Incruse Ellipta (umeclidinium) LAMA May 2014 Anoro Ellipta (umeclidinium + vilanterol) LABA/LAMA Dec 2013 Breo Ellipta (flulcasone + vilanterol) ICS/LABA May 2013 PROS CONS Comparison of Inhaled Treatments Short- ac?ng LABA LAMA ICS For palents with occasional symptoms Response less rapid in COPD than asthma Adherence difficult No evidence for addilon to long- aclng agents exacerbalon rate Salmeterol hospitalizalons Can worsen tremor May precipitate arrhythmias in high risk palents Tiotropium exacerbalon rate and hosp ns Tiotropium may be > salmeterol Dry mouth QuesLonable signal of CV events and mortality with ipratropium and Lotropium SMI symptoms & exacerbalons Bronchodilator + ICS may mortality Adverse effects candidiasis myopathy pneumonia bone density? cataracts Withdrawal? 16

17 IniLal Treatment Assessing Treatment Response GOLD 4 GOLD 3 GOLD 2 GOLD 1 C LABA/ICS or LAMA LABA/LAMA or LAMA + PDE- 4 inhibitor or LABA + PDE- 4 inhibitor A SABA or SAMA PRN LABA or LAMA or SABA/ SAMA D LABA/ICS ± LAMA ± PDE- 4 inhibitor or LABA/LAMA or LAMA + PDE- 4 inhibitor B LABA or LAMA LABA/LAMA 2 (or 1 leading to hosp) 1 (not leading to hosp) 0 No. exacerbalons/year Have you nolced a difference since starlng this treatment? If you are bener: o Are you less breathless? o Can you do more? o Can you sleep bener? o Describe what difference it has made to you. Is that change worthwhile to you? CAT < 10 (Symptoms) CAT 10 17

18 PaLent Case Maverick (63 y/o male), newly diagnosed with COPD. No history of exacerbalons. FEV1 is 60% predicted, CAT score is 12 (GOLD Group B). Symptoms are mainly dyspnea on exerlon and falgue. No characterislcs consistent with asthma. What would you recommend as inilal treatment for Maverick? A. Combivent Respimat (SABA/SAMA) PRN B. Spiriva Respimat (LAMA) 2 inhalalons daily C. SLolto Resipmat (LABA/LAMA) 2 inhalalons daily GOLD 4 GOLD 3 GOLD 2 GOLD 1 C IniLal Treatment LABA/ICS or LAMA LABA/LAMA or LAMA + PDE- 4 inhibitor or LABA + PDE- 4 inhibitor A SABA or SAMA PRN LABA or LAMA or SABA/ SAMA D LABA/ICS ± LAMA ± PDE- 4 inhibitor or LABA/LAMA or LAMA + PDE- 4 inhibitor B LABA or LAMA LABA/LAMA 2 (or 1 leading to hosp) 1 (not leading to hosp) 0 No. exacerbalons/year D. Breo Ellipta (LABA/ICS) 1 inhalalon daily CAT < 10 (Symptoms) CAT 10 18

19 LABA/LAMA vs LABA/ICS ILLUMINATE study (Lancet Respir Med 2013) o Indacaterol/glycopyrrionium vs flulcasone/salmeterol o PaLents without previous exacerbalons (majority COPD Group B) o 138 ml improvement in FEV 1 LABA/LAMA vs week 26 LABA/LAMA vs LABA/ICS LANTERN study (Int J COPD 2015) o Indacaterol/glycopyrrionium vs flulcasone/salmeterol o PaLents with 0-1 exacerbalon in previous year (Groups B and D) o Primary endpoint: FEV 1 ; Secondary endpoint: exacerbalons Vogelmeier et al. Lancet Respir Med. 2013;1: Zhong et al. Int J COPD. 2015;10:

20 LABA/LAMA vs LABA/ICS LANTERN study (Int J COPD 2015) o Indacaterol/glycopyrrionium vs flulcasone/salmeterol o PaLents with 0-1 exacerbalon in previous year (Groups B and D) o Primary endpoint: FEV 1; Secondary endpoint: exacerbalons LABA/LAMA vs LAMA SPARK study (Lancet Respir Med. 2013) o Indacaterol/glycopyrronium vs glycopyrronium vs Lotropium o GOLD Group C and D (at least 1 exacerbalon previous year) o 12% reduclon in exacerbalons LABA/LAMA vs Glycopyrronium o Similar adverse events in all 3 groups, most frequent: COPD worsening FluLcasone/salmeterol Indacaterol/glycopyrronium Zhong et al. Int J COPD 2015;10: Wedzicha et al. Lancet Respir Med. 2013;1(3):

21 Monotherapy vs Dual BronchodilaLon Insurance Coverage LABA/ LAMA Combo S?olto Respimat Anoro Ellipta U?bron Neohaler Humana Medicare Pref Pref NC BCBS Medicare NC Pref NC Silverscript Medicare NC Pref NC Presbyterian Medicare NC Tier 4 (ST) NC AARP Medicare Pref Pref NC BCBS Centennial NC NC NC Molina Centennial NC NC NC Pres Centennial NC Pref NC UHC Centennial NC Pref NC Express Scripts Pref Pref NC Pref = Preferred; NC = Not Covered; ST = Step Therapy Adapted from Beeh KM, Beier J. Adv Ther. 2010;27: As of March 31,

22 PaLent Case 69 year old female with a history of COPD, diagnosed 2 years ago with hospital admission for exacerbalon. History of smoking, quit 2 years ago aser exacerbalon. No exacerbalons within last 2 years. CAT score = 17, chronic cough and sputum. FEV 1 = 52%. On Symbicort 160/4.5 mcg, 2 puffs BID. How should this palent s COPD be treated? ICS Withdrawal Studies COSMIC study 2005 o History of 2 or more exacerbalons in last year o 3 month run- in with salmeterol/flulcasone Followed by 12 months treatment with salmeterol vs salmeterol/flulcasone o Decrease in lung funclon (FEV 1 ) but no change in exacerbalon rate WISDOM study (NEJM 2014) o GOLD Groups C and D o 6 week run in with ICS/LABA/LAMA Randomized to 3- step withdrawal of ICS or conlnued triple therapy x 1 year o No difference in Lme to exacerbalon (primary endpoint) o 5% decrease FEV 1 (38 ml), no increase in symptoms Occurs over first 3 weeks, then no further decline (Magnussen et al 2016) Wouters et al. Thorax. 2005;60(6): Magnussen et al. N Engl J Med. 2014;371(14): Magnussen. Eur Respir J 2016; 47:

23 ICS Withdrawal Studies INSTEAD study (Eur Resp J 2014) o Less severe COPD, no history of exacerbalons o PaLents on at least 3 months of flulcasone/salmeterol o Randomized to conlnued therapy or switch to indacaterol x 26 weeks o Primary outcome: FEV1 - no change Not powered for exacerbalons, but rate numerically lower with indacaterol than flulcasone/salmeterol Controversial Role of ICS European Medicines Agency o Pharmacovigilance Risk Assessment Comminee (PRAC) o March 18, 2016 Results of PRAC Review of ICS Confirmed increased risk of pneumonia with ICS in COPD No difference in rate of pneumonia between different ICS inhalers Benefits of ICS use slll outweigh risk of pneumonia o AwaiLng the Agency s final stance on whether ICS are safe Rossi et al. Eur Respir J 2014;44:

24 Controversial Role of ICS From the 2016 GOLD Guidelines Long- term treatment with inhaled corlcosteroids is recommended for palents with severe and very severe COPD and frequent exacerba?ons that are not adequately controlled by long- aclng bronchodilators Asthma- COPD Overlap Syndrome (ACOS) Treatment: ICS, usually with long- aclng bronchodilator(s) Long- term treatment containing inhaled corlcosteroids should not be prescribed outside their indicalons, due to the risk of pneumonia and the possibility of an increased risk of fractures following long- term exposure 24

25 PaLent Case 69 year old female with a history of COPD, diagnosed 2 years ago with hospital admission for exacerbalon. History of smoking, quit 2 years ago aser exacerbalon. No exacerbalons within last 2 years. CAT score = 17, chronic cough and sputum. FEV1 = 52%. On Symbicort 160/4.5 mcg, 2 puffs BID. How should this palent s COPD be treated? New Algorithm for COPD Management (Proposed) Cooper et al. Lancet Respir Med. 2015;3:

26 Available Devices Devices and AdministraLon MDI Metered dose inhaler Difficult to coordinate breath Valved holding chamber helpful Contains propellants DPI Dry powder inhaler Requires forceful inhalalon SMI Sos mist inhaler Slow steady mist No shaking or spacer required Nebulizer Not portable Expensive No coordinalon of breath required ConLnue only if symptomalc benefit clear Device seleclon depends on palent characterislcs and cost/insurance formulary 26

27 Dry Powder Inhalers (DPI) Ellipta All- In- One Devices Trade Name(s) Device Inhala?on Advair (LABA/ICS) Serevent (LABA) Tudorza (LAMA) Breo (LABA/ICS) Anoro (LABA/LAMA) Arnuity (ICS) ProAir (SABA) Diskus Pressair Ellipta RespiClick Quick, deep breath Long, steady, deep breath 27

28 Insurance Coverage LAMA Tudorza Pressair Spiriva Handihaler Spiriva Respimat Incruse Ellipta Seebri Neohaler Humana Medicare Tier 4 (NP) Pref Pref NC NC BCBS Medicare NC Pref Pref NC NC Silverscript Medicare NC NC Tier 4 (NP) Pref NC ProAir RespiClick Presbyterian Medicare Pref Pref Pref NC NC AARP Medicare NC Pref Pref NC NC BCBS Cent NC Pref Pref Pref NC Molina Cent Pref NC NC Pref NC Pres Cent Pref Pref Pref NC NC UHC Cent NC NC NC Pref NC Express Scripts Pref Pref Pref Pref NC OPEN INHALE CLOSE As of March 31,

29 Dry Powder Inhalers (DPI) Neohaler Assembly- Required Devices Trade Name Device Inhala?on Spiriva (LAMA) Foradil (LABA) Arcapta TM (LABA) ULbron (LABA/LAMA) Handihaler Aerolizer Neohaler Neohaler TM Neohaler Quick, deep Quick, deep breath breath 29

30 Sos Mist Inhalers (SMIs) Trade Name Device Inhala?on Respimat First Time Use Combivent (SABA/SAMA) Spiriva (LAMA) SLolto (LABA/LAMA) Striverdi (LABA) Respimat Slow, deep breath Load cartridge Prime Ready to use 30

31 Respimat Inhaled Short- AcLng Bronchodilators Drug Device Dose Frequency Dura?on of Ac?on Albuterol ProvenLl HFA ProAir HFA Ventolin HFA Albuterol ProAir Albuterol AccuNeb Levalbuterol Xopenex HFA Levalbuterol Xopenex MDI Respiclik (DPI) Nebulized SoluLon MDI Nebulized SoluLon SABA 1-2 puffs (90 mcg/puff) 1-2 inhalalons (90 mcg/puff) every 4-6 hours PRN every 4-6 hours PRN 2.5 mg every 4-6 hours PRN 2 puffs (45 mcg/puff) every 4-6 hours PRN 0.63 mg every 6-8 hours PRN 4-6 hours 4-6 hours 4-6 hours 6-8 hours 6-8 hours 31

32 Inhaled Short- AcLng Bronchodilators SAMA Drug Device Dose Frequency Dura?on of Ac?on Ipratropium Atrovent HFA Ipratropium MDI Nebulized SoluLon 2 puffs (17 mcg/puff) four Lmes daily, up to 12 puffs/ day 6-8 hours 0.5 mg every 6-8 hours 6-8 hours SABA + SAMA Drug Device Dose Frequency Dura?on of Ac?on Ipratropium / albuterol Combivent Ipratropium / albuterol Duoneb Respimat SMI Nebulized SoluLon 1 inhalalon (20 mcg/100 mcg) every 6 hours, up to every 4 hours 0.5 mg/2.5 mg every 6 hours, up to every 4 hours 6-8 hours 6-8 hours Inhaled Long- AcLng Bronchodilators Salmeterol Serevent Formoterol Foradil Drug Device Dose Frequency Dura?on of Ac?on Formoterol Perforomist Arformoterol Brovana Indacaterol Arcapta TM Olodaterol Striverdi Diskus DPI Aerolizer DPI Nebulized SoluLon Nebulized SoluLon Neohaler TM DPI Respimat SMI LABA 1 inhalalon (50 mcg tab) 1 inhalalon (12 mcg cap) twice daily twice daily 12 hours 12 hours 20 mcg twice daily 12 hours 15 mcg twice daily 12 hours 1-2 inhalalon (75 mcg cap) 2 inhalalons (2.5 mcg) once daily once daily 24 hours 24 hours 32

33 Inhaled Long- AcLng Bronchodilators Tiotropium Spiriva Tiotropium Spiriva Aclidinium Tudorza TM Drug Device Dose Frequency Dura?on of Ac?on Umeclidinium Incruse TM Glycopyrrolate Seebri Handihaler DPI Respimat SMI Pressair TM DPI Ellipta TM DPI Neohaler (DPI) LAMA 2 inhalalons (18 mcg cap) 2 inhalalons (2.5 mcg/inh) 1 inhalalon (400 mcg tab) 1 inhalalon (62.5 mcg) once daily once daily twice daily once daily 24 hours 24 hours 12 hours 24 hours LAMA Twice a day 12 hours Flu.casone propionate Flovent HFA Flu.casone propionate Flovent Single Agent Inhaled CorLcosteroids Drug Device Dose Frequency Beclomethasone Qvar HFA Budesonide Pulmicort Flu.casone furoate Arnuity MDI Diskus DPI MDI Flexhaler MDI ElliptaTM DPI 1 puff (250 mcg/puff) 1 inhalalon (50 mcg/inh) 40 to 400 mcg per day 1 puff (180 mcg/puff) 1 puff (100 or 200 mcg/ puff) twice daily twice daily twice daily twice daily once daily No single- agent ICS are FDA- approved for COPD; should be used with long- aclng bronchodilator 33

34 Inhaled CombinaLon Products Drug Device Dose Frequency Flu=casone propionate/ salmeterol Advair Budesonide/formoterol Symbicort Flu=casone furoate/ vilanterol Breo Diskus DPI MDI Ellipta TM DPI LABA/ICS 1 inhalalon (250/50 mcg) 2 puff (160/4.5 mcg) 1 inhalalon (100/25 mcg) twice daily twice daily once daily Dura?on of Ac?on 12 hours 12 hours 24 hours Inhaled CombinaLon Products LABA/LAMA Drug Device Dose Frequency Dura?on of Ac?on Anoro TM Umeclidinium/ Vilanterol SLolto Tiotropium/ olodaterol ULbron Glycopyrronium/ Indacaterol Ellipta TM DPI Respimat SMI Neohaler (DPI) Assembly required 1 inhalalon (62.5/25 mcg) 2 inhalalons (2.5/2.5 mcg/inh) once daily once daily 24 hours 24 hours LABA/LAMA twice a day 12 hours 34

35 In the Pipeline PDE3 and PDE4 inhibitors for inhalalon Nucala (mepolizumab) IL5 antagonist Budesonide/formoterol/glycopyrronium combinalon inhaler Summary COPD o GOLD combined assessment: symptoms (CAT score), FEV 1, and exacerbalon history o Long- aclng bronchodilators for most palents o Inhaled corlcosteroids only for palents with high exacerbalon risk o Longer- aclng and combinalon formulalons becoming more available Gross. COPD. 2016; 3(1):

36 Summary GOLD combined assessment: symptoms (CAT score), FEV 1, and exacerbalon history Pharmacotherapy improves symptoms and reduces risk of exacerbalons, but no impact on mortality or lung decline Long- aclng bronchodilators for most palents Inhaled corlcosteroids only for palents with high exacerbalon risk Safe to withdraw ICS in non- exacerbators without characterislcs of asthma Longer- aclng and combinalon formulalons becoming more available QuesLons? Juliann Horne 36

37 References Global Strategy for the Diagnosis, Management and Preven.on of COPD, Global IniLaLve for Chronic ObstrucLve Lung Disease (GOLD) Available from: hnp:// American Lung AssociaLon. Chronic obstruclve pulmonary disease (COPD) fact sheet. Updated May Accessed at hnp:// disease/copd/resources/ facts- figures/copd- Fact- Sheet.html. Accessed on February 23, CenterWatch. FDA Approved Drugs for Pulmonary/Respiratory Diseases. Updated March Accessed at hnps:// informalon/fda- approved- drugs/therapeulc- area/18/pulmonary- respiratory- diseases. Accessed on May 8, Lexicomp Online, Lexi- Drugs, Hudson, Ohio: Lexi- Comp, Inc.; January 29, Fletcher C, Peto R. The natural history of COPD. BMJ. 1977;1: Gross N. COPD pipeline XXX. Chronic Obstr Pulm Dis (Miami). 2016; 3(1):

38 Stable COPD IniLal Management Pa?ent Group First Choice Second Choice Group A Group B SABA PRN or SAMA PRN LABA or LAMA LABA or LAMA or SABA + SAMA LABA + LAMA Stable COPD IniLal Management Pa?ent Group First Choice Second Choice Group C Group D ICS + LABA or LAMA ICS + LABA or ICS + LAMA LABA + LAMA or LAMA + PDE- 4 inhibitor* or LABA + PDE- 4 inhibitor* ICS + LABA + LAMA or ICS + LABA + PDE- 4 inhibitor* or LABA + LAMA or LAMA+ PDE- 4 inhibitor* *PDE- 4 inhibitor only recommended if chronic bronchils present 38

39 Oral Treatments for COPD Methylxanthines (theophylline, aminophylline) o Narrow therapeulc index, drug interaclons o Less well tolerated and less effeclve than inhaled bronchodilators MucolyLcs o N- acetylcysteine may have anloxidant effects, could have a role in the treatment of palents with recurrent exacerbalons (Evidence B). o Roflumilast (Daliresp) Oral Treatments for COPD PDE- 4 inhibitor (roflumilast = Daliresp ) o Approved February 2011 o 500 mcg PO daily o Inhibits inflammalon by prevenlng breakdown of camp o Adverse effects: diarrhea, weight loss; suicide caulon o Contraindicated in moderate to severe hepalc insufficiency o Always use in combinalon with at least one long- aclng bronchodilator o Reduces exacerbalons in palents with severe COPD (FEV 1 < 50% predicted, chronic bronchils, frequent exacerbalons) 39

40 REACT Trial (March 2015) 1- year, double- blind, controlled, mullcenter study Inclusions o Age 40 or older o 20 pack- years or more o FEV 1 50% predicted, symptoms of chronic bronchils, history of 2 or more exacerbalons in the past year, with cough and sputum o On LABA/ICS ± LAMA for 12 months Randomized to roflumilast/placebo + baseline inhaled therapy Results (n=1,945) o 15-20% reduclon in moderate to severe exacerbalons o Improvements in pulmonary funclon tests o No difference in palent reported symptoms Spirometry Results Martinez et al. Lancet. 2015;385:

41 Available Products by Device Medica?on MDI DPI SMI Nebulized Albuterol ProvenLl HFA Proair HFA Ventolin HFA AccuNeb Levalbuterol Xopenex HFA Xopenex Ipratropium Atrovent HFA Ipratropium Albuterol/ Ipratropium Salmeterol Serevent Diskus Combivent Respimat Duoneb Formoterol Foradil Aerolizer Perforomist Arformoterol Indacaterol Olodaterol Arcapta Neohaler Striverdi Respimat Brovana Available Products by Device Medica?on MDI DPI SMI Nebulized Tiotropium Spiriva Handihaler Spiriva Respimat Aclidinium Umeclidinium FluLcasone propionate Beclomethasone Flovent HFA Qvar HFA Tudorza Pressair Incruse Ellipta Flovent Diskus Budesonide Pulmicort Flexhaler Budesonide FluLcasone prop/ salmeterol Budesonide/ formoterol Mometasone/ formoterol FluLcasone furoate/vilanterol Umeclidinium/ vilanterol Advair HFA Symbicort Dulera Advair Diskus Breo Ellipta Anoro Ellipta 41

42 DefiniLon NO CURE Common preventable and treatable pulmonary disease Characterized by airflow limitalon Chronic inflammatory response in the airways and the lung to noxious gases/parlcles Usually progressive Characterized by emphysema and chronic bronchils No cure 42

43 COPD Cycle COPD COPD & ComorbidiLes CAD, heart failure, atrial fibrillalon, and hypertension should be treated according to current guidelines Depression Dyspnea Lack of Fitness o In Afib, use of high doses of beta- agonists can make heart rate control more difficult Beta- blockers o When indicated, B- blocker benefits outweigh risk o Consider B1 seleclve if possible Social IsolaLon Immobility 43

44 Pressair Tudorza Pressair (aclidinium) New FDA Warning April 2015 Based on post- markelng reports 44

45 Advair Diskus Spiriva Handihaler 45

46 Foradil Aerolizer 46

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