COPD in Transitions of Care an opportunity for Pharmacists

Transcription

1 COPD in Transitions of Care an opportunity for Pharmacists Chad Worz, Pharm.D. Chief Executive Officer, The American ociety of Consultant Pharmacists Objectives and Agenda Recognize the burden of disease in older adults Acknowledge Burden on our Health Care ystem Describe the pharmacology of treatments and their impact on the disease process Demonstrate the varied administration methods for treatments and the importance in post acute care Recognize the new Treatment Guidelines for COPD Define the role of the pharmacist COPD Defined. Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. 1

2 COPD Defined. The most common respiratory symptoms include dyspnea, cough and/or sputum production. These symptoms may be under-reported by patients. The main risk factor for COPD is tobacco smoking but other environmental exposures such as biomass fuel exposure and air pollution may contribute. Besides exposures, host factors predispose individuals to develop COPD. These include genetic abnormalities, abnormal lung development and accelerated aging. COPD Has Been hown to Be a Common and Costly Condition COPD is the 3rd leading cause of death in the United tates 1,2 COPD is the 2nd leading cause of disability 3 By 2010, there were 14.8 million diagnosed COPD patients in the U 4 COPD accounts for an estimated $29.5 billion in direct healthcare expenses 5 1. Kochanek KD, et al. Deaths: Preliminary data for National vital statistics reports. 2011;59: Miniño AM, et al. Deaths: Preliminary data for National vital statistics reports. 2010;59: Wise RA. Chronic Obstructive Pulmonary Disease (COPD): Merck Manual Home Edition National Heart, Lung, and Blood Institute. Unpublished Tabulations of the National Health Interview urvey, Accessed June American Lung Association. Chronic obstructive pulmonary disease (COPD) fact sheet. Accessed May 23,

3 COPD in Long Term Care One of every six admissions to nursing homes was for patients with a history of emphysema or COPD 1 In the last 12 months of COPD patients lives, one recent study reported there was a 40% likelihood of being admitted to a LTC facility 2 Approximately 22% of the respiratory-related healthcare costs are nursing home costs; a greater amount was spent on hospitalizations (approximately 50%) 1. Kochanek KD, Xu J, Murphy L, Miniño AM, Kung HC. Deaths: preliminary data for National vital statistics reports. 2011;59: Miniño AM, Xu J, Kochanek, KD. Deaths: preliminary data for National vital statistics reports. 2010;59: COPD in Long Term Care The majority of persons with COPD have cardiovascular disease including coronary artery disease, heart failure, and hypertension. troke occurs in a significant portion of persons with COPD. About 25% of persons with COPD have concurrent asthma. Age-related and steroid-induced osteoporosis occur frequently in persons with the disease, and COPD is a risk factor for nursing home associated pneumonia. A significant number of persons with COPD have obstructive sleep apnea. National Heart, Lung, and Blood Institute. Unpublished Tabulations of the National Health Interview urvey, Accessed June COPD in Long Term Care Depression and anxiety are also common in COPD; one study found that 40% of persons with COPD have depressive symptoms. Diabetes mellitus occurs in about 25% of persons with COPD. Malnutrition is a significant issue in some individuals with COPD. ubstantial chronic airway obstruction leads to greater energy requirements due to the increased work of breathing, as well as inactivity from deconditioning Wise RM. Chronic Obstructive Pulmonary Disease. Chronic Obstructive Pulmonary Disease (COPD): Merck Manual Home Edition. Whitehouse tation, NJ: Merck harp & Dohme Corp., a subsidiary of Merck & Co., Inc.,

4 Economic Burden of COPD Annual cost in the U: $30.4 billion 1 Direct cost: $14.7 billion Indirect cost: $15.7 billion Emergency services, hospitalization Per capita Medicare expenditure nearly 2.5 times higher with a COPD diagnosis than without 2 $8,482 vs. $3,511 without COPD Diagnosis of chronic respiratory disease is associated with a 172% increase in mean health care costs 3 1. American Lung Association. COPD Fact heet Grasso ME et al. Am J Respir Crit Care Med. 1998;158: Fishman P et al. Health Aff. 1997;16: Correlation Between Disease everity and Total Treatment Cost 1 Retrospective pharmacoeconomic analysis 413 patients, 5 years tage 1 (Mild) COPD: $ 1,681/patient/year tage 2 (Moderate) COPD: $ 5,037/patient/year tage 3 (evere) COPD: $10,812/patient/year 1. Hilleman DE et al. Chest. 2000;118: tepwise Approach to Treament Early and accurate diagnosis Prevention of disease progression (deterioration of pulmonary function) Relief of symptoms Improvement in exercise tolerance and health status Wise RM. Chronic Obstructive Pulmonary Disease. Chronic Obstructive Pulmonary Disease (COPD): Merck Manual Home Edition. Whitehouse tation, NJ: Merck harp & Dohme Corp., a subsidiary of Merck & Co., Inc.,

5 tepwise Approach to Treament Prevention and treatment of exacerbations and complications Improvement in quality of life Reduction in mortality Includes drug therapy, smoking cessation, oxygen, pulmonary rehabilitation, and nutritional intervention. Wise RM. Chronic Obstructive Pulmonary Disease. Chronic Obstructive Pulmonary Disease (COPD): Merck Manual Home Edition. Whitehouse tation, NJ: Merck harp & Dohme Corp., a subsidiary of Merck & Co., Inc., GOLD GUIDELINE From the Global trategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) Available from: 14 Maintenance Therapy for Long-term COPD Care Considerations Focus of COPD care is shifting from acute treatment to long-term maintenance 1-3 Many patients did not receive any maintenance COPD therapy 4 GOLD can be used to inform the prescribing of maintenance therapy 3,5 When selecting an inhaled COPD therapy, drug delivery and training should be considered 5 1. Centers for Medicare & Medicaid ervices. Accountable Care Organization 2012 program analysis. Quality performance standards narrative measure specifications. Final report. Accessed May 23, National Committee for Quality Assurance. Insights for quality improvement: advancing COPD care through quality improvement Available at Accessed May 23, Fromer L. Int J Chron Obstruct Pulmon Dis. 2011;6: Make B, et al. Int J Chron Obstruct Pulmon Dis. 2010;5: Global Initiative for Chronic Obstructive Lung Disease (GOLD). Accessed May 14,

6 Maintenance Therapy for Long-term COPD Care Considerations In the hospital prior to discharge, patients should start long-acting bronchodilators, either beta 2 -agonists and/or anticholinergics with or without inhaled corticosteroids 5 Add 1 or more classes of long-acting bronchodilators when needed 5 1. Centers for Medicare & Medicaid ervices. Accountable Care Organization 2012 program analysis. Quality performance standards narrative measure specifications. Final report. Accessed May 23, National Committee for Quality Assurance. Insights for quality improvement: advancing COPD care through quality improvement Available at Accessed May 23, Fromer L. Int J Chron Obstruct Pulmon Dis. 2011;6: Make B, et al. Int J Chron Obstruct Pulmon Dis. 2010;5: Global Initiative for Chronic Obstructive Lung Disease (GOLD). Accessed May 14, Risk Factors for COPD moking is the predominant risk factor 1,2 Implicated in >90% of U patients with COPD Others include 1 : Air pollution Poor nutrition Childhood respiratory infections Preexisting bronchial hyperreactivity a 1 -Antitrypsin deficiency (genetic, rare) Occupational and environmental exposure (eg, coal dust, silica) 1. NCAP. J Respir Dis. 2000;21(uppl): Buist A, Vollmer WM. In: Textbook of Respiratory Medicine. 1994: Risk Factors for COPD 1. NCAP. J Respir Dis. 2000;21(uppl): Buist A, Vollmer WM. In: Textbook of Respiratory Medicine. 1994:

7 Age-Related Decline in FEV 1 Is Accelerated in mokers FEV 1 (% of value at age 25 y) Disability Death Age (y) Never smoked or not susceptible to smoke topped at 45 y topped at 65 y Adapted with permission from Fletcher C, Peto R. BMJ. 1977;1: Age-Related Decline in FEV 1 Is Accelerated in mokers Mechanisms of Airflow Limitation in COPD Pharmacological Reviews December 2004, 56 (4) ; DOI: 7

8 Pharmacotherapy: Anticholinergic Agents Block bronchoconstriction Increase FEV 1 Have been shown to reduce exacerbation rate May be associated with lower treatment costs 1,2 Anti-cholinergics are considered first line 3-5 Minimal side effects Do not cross blood-brain barrier Minimal gastrointestinal absorption Extended therapy associated with improved baseline pulmonary function 6 1. NCAP. J Respir Dis. 2000;21(suppl): Friedman et al. Chest. 1999;115: NLHEP. 1998:113(suppl): PDR.net. Atrovent Inhalation Aerosol. 5. AT Am J Respir Crit Care Med. 1995;152: Rennard I et al. Chest. 1996;110: Cholinergic Tone Barnes PJ: β 2-agonists, anticholinergics, and other nonsteroid drugs. In Albert RK, editor: Clinical respiratory medicine, ed 3, Philadelphia, Mosby, 2008 Long-Acting b 2 -Adrenergic Agonists 1 Effective in improving FEV 1 and FVC, and may reduce COPD exacerbations May provide relief from nocturnal symptoms Can be used with ipratropium if short-acting b 2 -agonist used frequently for rescue Unlike short-acting b 2 -agonists, NOT for rescue 1. NCAP. J Respir Dis. 2000;21(suppl):

9 Inhaled Corticosteroids If response to anticholinergic and other bronchodilator therapy is suboptimal, inhaled corticosteroid therapy may provide benefit in some patients 1 Indicated only in patients who are already receiving chronic low-dose corticosteroid therapy, or who have a documented objective response to corticosteroid therapy 1. NCAP. J Respir Dis. 2000;21(suppl): Vestbo J et al. Lancet. 1999;353: Pauwels RA et al. N Engl J Med. 1999;340: The Lung Health tudy Research Group. N Engl J Med. 2000;343: Burge P et al. BMJ. 2000;320: Inhaled Corticosteroids 4 major studies have been conducted 2 5 No effect on mortality, rate of decline of FEV 1 No significant increase in FEV 1 short term 1. NCAP. J Respir Dis. 2000;21(suppl): Vestbo J et al. Lancet. 1999;353: Pauwels RA et al. N Engl J Med. 1999;340: The Lung Health tudy Research Group. N Engl J Med. 2000;343: Burge P et al. BMJ. 2000;320: hort-acting b 2 -Adrenergic Agonists If response to initial anticholinergic therapy suboptimal, add b 2 -adrenergic agonist 1,2 Combination MDI (ipratropium and albuterol) 1,3,4 : Greater efficacy, equivalent safety Lower rate of exacerbations Lower total treatment costs Improved cost-effectiveness MDI, metered-dose inhaler 1. Combivent Inhalation Aerosol tudy Group. Chest. 1994;105: NCAP. J Respir Dis. 2000;21(suppl): Campbell. Arch Intern Med. 1999;159: Friedman M et al. Chest. 1999;115:

10 PDE4 Inhibitors Roflumilast therapy has a limited role in patients with severe COPD, and no role in patients with mild to moderate COPD. It will not decrease the number of hospitalizations. It will slightly lower the number of exacerbations requiring oral corticosteroid treatment, but only in select patients (i.e., those with a combination of severe COPD, current bronchitic symptoms, and a previous exacerbation). Am Fam Physician Feb 15;89(4): Theophylline 1 If response to initial anticholinergic/b 2 -agonist therapy suboptimal, consider adding theophylline Long-acting formulations generally preferred Modest bronchodilation, mild anti-inflammatory effects Useful for noncompliant patients and those who have trouble with inhalation aerosols and those preferring oral drugs Titrate dose to serum level up to a maximum of 12 µg/ml ome patients experience side effects at lower serum levels 1. NCAP. J Respir Dis. 2000;21(suppl):5-21. Anti-Inflammatory Agents If bronchodilator response is suboptimal, consider adding an anti-inflammatory drug 1 Corticosteroids (oral/inhaled) Useful in few patients 1 Consider 2-week trial of oral corticosteroid (40 mg prednisone QD) Discontinue if no response If patient responds, taper to minimal effective dose level and switch to inhaled corticosteroid 1. NCAP. J Respir Dis. 2000;21(suppl): Callahan CM et al. Ann Intern Med. 1991;114: Chanez P et al. Am J Respir Crit Care Med. 1997:155: Pizzichini E et al. Am J Respir Crit Care Med. 1998;158(5 pt 1):

11 Anti-Inflammatory Agents Limited role in chronic COPD 10% improve FEV 1 20% 2 May actually detect hidden asthma 3,4 Cromolyn, nedocromil, and leukotriene modifiers have not been proven effective in COPD 1 1. NCAP. J Respir Dis. 2000;21(suppl): Callahan CM et al. Ann Intern Med. 1991;114: Chanez P et al. Am J Respir Crit Care Med. 1997:155: Pizzichini E et al. Am J Respir Crit Care Med. 1998;158(5 pt 1): Long-Term Oxygen Therapy Indicated for PaO 2 <55 mm Hg or ao 2 <88% 1 Improves 1-4 : urvival in hypoxemic patients Cognitive function, affect Exercise performance leep quality Activities of daily living 1. NCAP. J Respir Dis. 2000;21(suppl): Report of the Medical Research Council Working Party. Lancet. 1981; Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93: Bye et al. Am Rev Respir Dis. 1985;132: Administration MDI (Metered Dose Inhaler) vs. HHN (Hand Held Nebulizer) A HHN is not superior to an MDI The problem is technique (consider a spacer) With optimal technique a MDI delivers close to 12% of the drug to the lung. In general, the HHN dose needs to be 6 to 10 times higher than the MDI to deliver the same degree of bronchodilation. Consider nursing administration time Consider the patient 11

12 Device Device Comparison Chronic obstructive pulmonary disease exacerbation and inhaler device handling: real-life assessment of 2935 patients. Handling errors were observed in over 50% of patients Critical errors compromising drug delivery were respectively made in 15.4%, 21.2%, 29.3%, 43.8%, 46.9% and 32.1% of inhalation assessment tests with Breezhaler, Diskus, Handihaler, pressurised metered-dose inhaler (pmdi), Respimat and Turbuhaler Eur Respir J Feb 15;49(2). pii: doi: / Print 2017 Feb. Device comparison Eur Respir J Feb 15;49(2). pii: doi: /

13 Post Acute and Long Term Care What does all of this mean to us? A New Focus on management and an effort to reduce hospitalizations Impact to NF Impact on therapeutic decisions Assessing devices and matching them to patients COT EFFECTIVENE Post Acute and Long Term Care Formulary development Assessment surveys or work ups Cost management Working with industry Education Discounts to Nursing Homes? Product placement Post Acute and Long Term Care Today: Hospitals work to discharge May or may not reconcile the medication list when sent to the nursing home Goal is to maximize pulse ox and limit resources (related to payment mechanisms) Not effective at medication counseling LTC day 1 clean up the profile on admission, limit cost 13

14 Post Acute and Long Term Care Tomorrow: Hospitals work to discharge Better data and reconciliation Recognition of penalties for re-hospitalizations May add resources for medication counseling LTC : Day 1 clean up the profile on admission Plan of Care for discharge Reconciliation and Counseling critical On the hook for re-hospitalizations Questions 14