9/14/12. Nicole Paterson, PharmD BCPS Medication Therapy Management Provider Fairview Pharmacy Services, LLC
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1 Nicole Paterson, PharmD BCPS Medication Therapy Management Provider Fairview Pharmacy Services, LLC } Describe the pathophysiology of asthma and Chronic Obstructive Pulmonary Disease (COPD). } Review the asthma and COPD guidelines and available treatment options. } Discuss how pharmacist can play a key role in asthma and COPD patient education. } A common chronic disorder of the airways that involves airflow obstruction, bronchial hyperresponsiveness and an underlying inflammation } Recurrent episodes of wheezing, chest tightness, shortness of breath, and cough } Widespread, variable, and reversible (not always completely) airflow obstruction 1
2 } Control chronic and nighttime symptoms Rules of two : Do you use a quick relief inhaler more than 2 times per week? Do you awaken at night due to asthma more than 2 times per month? Do you refill your quick relief inhaler prescription more than 2 times per year? } Maintain normal activity levels, including exercise } Maintain near-normal pulmonary function } Prevent acute episodes of asthma } Minimize emergency department visits and hospitalizations } Avoid adverse effects of asthma medications Baylor Healthcare System } Social history: Works as football coach, married } Current complaint: Feels asthma may contribute to difficulty going back to sleep after getting up to go to the bathroom. } Asthma: Uses albuterol nebulizer in the AM and at bedtime, he feels relaxation for about 4 hours and then his breathing becomes less comfortable. Notices symptoms after heavy lifting, such as snow shoveling. He has run out of his rescue inhaler. } Former smoker of cigars, rare alcohol use } Vaccinations: influenza vaccine this year, Tdap 2009 } Medications for Asthma & Allergies: albuterol 0.83% nebs 3ml every 4 hours prn, cetirizine 10mg QD (reports allergies are good) } On theophylline 200mg SR twice daily for post infarct adenosine release and bradyarrthymias. Hospital note from cardiology in 2010 plan was to stop this. } Comorbid conditions: hypertension, hyperlipidemia, arteriosclerotic cardiovascular disease (MI, angioplasty & stent 2010), rosacea, squamous cell carcinoma of skin } Weight: 266 lbs, BP 135/73 P 90 } Asthma Control Test=15, theophylline level 2.6 2
3 Asthma Mechanism } Controller Medications Daily Long-term control Anti-inflammatory } Reliever (rescue) Medications As needed Quick relief Bronchodilators 3
4 Controller Medications - Daily Corticosteroids (inhaled and systemic) (ICS) Long-acting beta 2 -agonists (LABA) Combination therapy Leukotriene modifiers (LTRA) Cromolyn sodium - Nedocromil sodium Sustained-release theophylline Allergy Immunotherapy - Omalizumab Reliever (or Rescue) Medications Short acting beta 2 -agonists (SABA) Systemic corticosteroids: Burst Therapy Anticholinergics Inhaled Beclomethasone (QVAR ) Budesonide (Pulmicort ) Fluticasone (Flovent ) Mometasone (Asmanex ) Ciclesonide (Alvesco ) Triamcinolone (Azmacort ) (n/a 2010) Flunisolide (AeroBid ) (n/a 2011) Systemic (Oral/IV) Prednisone (generic) Methylprednisolone (Medrol, Solu-medrol ) Prednisolone (Prelone ) } Most effective long-term control therapy for persistent asthma } Reduced airway inflammation Decreases airway hyperresponsiveness Stabilize the lung tissue } Maximum Effects: Inhaled: Days to Weeks (maybe months) Versus Oral prednisone: 6 to 24 hours **NEVER FOR RESCUE PURPOSES** 4
5 Inhaled Local } Dysphonia } Thrush } Cough/throat irritation } Impaired growth rate (high dose??) Systemic (oral, IV) } Fluid retention } Muscle weakness } Ulcers } Malaise } Impaired wound healing } Mood alteration } Weight gain } Impaired glucose } Hypertension } N/V, HA } Osteoporosis (adults) } Cataracts (adults) } Glaucoma (adults) } Salmeterol (Serevent ), Formoterol (Foradil ) Indication: Daily long-term control bronchodilator } Mechanism Long term stimulation of beta 2 receptors } Advantages Blunt exercise induced symptoms for longer time Decrease nocturnal symptoms Improve quality of life } Side effects Tachycardia, skeletal muscle tremor, hypokalemia, prolongation of QTc interval in overdose } NOT for acute symptoms or exacerbations Onset of effect: 3 minutes (formoterol), 30 minutes (salmeterol) Duration of effect: up to 12 hours } NOT a substitute for anti-inflammatory therapy } NOT FOR MONOTHERAPY IN ASTHMA Found an increased risk of severe asthma exacerbation leading to hospitalization and even death when using LABA for asthma prevention 5
6 } Fluticasone/Salmeterol (Advair Diskus and HFA) Disk: 1 inhalation twice daily Low 100/50, Medium 250/50, High 500/50 HFA: 2 puffs twice daily Low 45/21, Medium 115/21, High 230/21 } Budesonide/Formoterol (Symbicort HFA) 2 puffs twice daily Low: 80/4.5, Medium: 160/4.5 } Mometasone/Formoterol (Dulera HFA ) 2 puffs twice daily Medium: 100/5, High: 200/5 } Prevent inflammation Montelukast (Singulair ) Once a day in PM 4 mg granules (in C.A.I.R), 4 mg, 5 mg chewable, 10 mg tablet Pediatric indication > 1 year No food restrictions Zafirlukast (Accolate ) Twice daily empty stomach Indicated > 5 yo Many drug interactions; monitor liver enzymes Zileuton (Zyflo CR ) 600mg IR QID, 1200mg ER BID Indicated > 12 yo Many drug interactions; monitor liver enzymes Short acting beta 2 -agonists } Albuterol (ProAir, Proventil, Ventolin ) } Levalbuterol (Xopenex ) } Pirbuterol (Maxair ) (n/a after 2013) Anticholinergics } Ipratropium (Atrovent ) Systemic corticosteroids Burst Therapy } Prednisone } Prednisolone (Prelone ) } Methylprednisolone (Medrol ) 6
7 Beta 2 -Agonist Increased heart rate Palpitations Nervousness Sleeplessness Headache Tremor Anticholingeric Drying of mouth and secretions Constipation Blurred vision if sprayed in eyes Produces less cardiac stimulation than SABAs Regularly scheduled use not generally recommended use as needed May lower effectiveness May increase airway hyperresponsiveness (Accessed 8/13/2012). (Accessed 8/13/2012). 7
8 } Actions: November mometasone inhaler started, refilled albuterol inhaler, theophylline discontinued, asthma education, referral in for sleep clinic } Follow-up: January he has cold exacerbation and urgent care visit added montelukast 10mg daily + prednisone taper } Feburary he had a asthma flare and he had stopped mometasone inhaler prior to this. Montelukast continued, fluticasone/salmeterol 250/50 disc 1 inh twice daily started + prednisone taper. Sleep apnea diagnosis. } May MTM follow-up ACT=23, missing montelukast at times, pneumoccocal vaccine given, Asthma Action Plan reviewed, continues to work on getting CPAP started. } Seasonal Influenza Yearly immunization-trivalent influenza vaccine (TIV) or high dose if >65 years old Not recommended: intanasal influenza vaccine (Flumist) } Pneumococcal Age >2 years: 23-valent polysaccharide vaccine (PPSV) if received high dose steroids in asthma Age >19 years old: PPSV if have asthma, COPD, or smoker Persons who received PPSV before age 65 years for any indication should receive another dose of the vaccine at age 65 years or later if at least 5 years have passed since their previous dose Recommended Adult Immunization Schedule United States From Advisory Committee on Immunization Practices (ACIP). MMWR 2012;61(No. 4). Accessed at vaccines/schedules/hcp/adult.html. Control Medication: Fluticasone/salmeterol disc 250/50 1 puff twice daily + montelukast 10mg daily Rescue Medication: Albuterol inh 2 puffs every 4 hours Allergies Triggers: Seasonal allergies, upper respiratory tract infections, smoke 8
9 } Infections Common Cold #1 Trigger } Allergens Animal dander Cockroaches Dust mites Mold Pollen Foods/additives } Irritants Smoke, dust, strong odors, cold/humid air } Behaviors Emotions, exercise, smoking } Social history: attends grade school } Current complaint: Mom reports she is hesitant to give her son medications due to side effects, he was doing better but getting some coughing recently. It was hard to tell when Matt was declining in symptoms, suddenly it was so severe. } PMH: Asthma diagnosed age 18 months, recent ER visit for asthma 1 month ago, last ER visit was 2 years prior } Medications for asthma that Mom brings in: Fluticasone inhaler 110mcg, Budesonide nebs, levalbuterol 0.63mg/3ml nebs, ipatropium nebs, montelukast 5mg chewable tab daily, prednisone 25mg twice daily for flares, has Optichamber spacer } Comorbid conditions: none } Asthma Triggers: Upper respiratory track infections } Asthma Control Test= 14 } Assessment: Inhaler technique poor 9
10 Optimal Technique: Shake inhaler for 10 seconds Actuation during a slow (30 l/m or 3-5 seconds) deep inhalation, followed by a 10 second breathhold. Under laboratory conditions, open-mouth technique (holding MDI 2 inches away from open mouth) enhances delivery to the lung. However, it has not consistently been shown to enhance clinical benefit compared to closed-mouth technique (closing mouth around MDI mouthpiece) The successful use of Metered Dose Inhalers requires that patients: } Shake inhaler } Inspire at actuation } Inhale slowly } Hold their breath } Exhale slowly } Easier to use, and more effective, than MDI alone } Spacers/holding chambers decrease oropharyngeal deposition and will reduce potential system absorption of inhaled corticosteriod preparations } A spacer device with a one-way valve, i.e., holding chamber, eliminates the need for the patient to coordinate actuation with inhalation and optimizes drug delivery. 10
11 (Accessed 8/13/2012). } Actions: Asthma education Educated on proper inhaler technique Consistently stay on fluticasone inhaler 110mg twice a day with spacer Do Peak Flow Meter Asthma Action Plan reviewed } Follow-up 1 month later: ACT=26, best peak flow was 220, AAP made with peak flow readings. If stable for next 3 months, consider step down to fluticasone 44mcg inhaler 1 puff twice a day. } Asthmatic vs. normal airways } What happens in an asthma attack } Control vs. Quick relief medications } Using controller medications regularly } How medications work (review inhaler technique) } Side effects of medications } Environmental control measures } Responding to changes in control } Following the Asthma Action Plan 11
12 } Preventable and treatable disease with some significant extrapulmonary effects that may contribute to the severity in individual patients } Airflow limitation that is not fully reversible } Usually progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases } Cough } Sputum production } Dyspnea on exertion } Episodes of acute worsening of these symptoms often occur Mechanisms Underlying Airflow Limitation in COPD Small Airways Disease Airway inflammation Airway fibrosis, luminal plugs Increased airway resistance Parenchymal Destruction Loss of alveolar attachments Decrease of elastic recoil AIRFLOW LIMITATION Adapted from Global Strategy for Diagnosis, Management and Prevention of COPD, (assessed 8/18/12) 12
13 } Relieve symptoms } Improve exercise tolerance } Improve health status Reduce Symptoms } Prevent disease progression Reduce } Prevent and treat exacerbations Risk } Reduce mortality } Prevent or minimize side effects from treatment Adapted from Global Strategy for Diagnosis, Management and Prevention of COPD, (assessed 8/18/12) } Social history: Was working as caretaker cleaning (exposed to chemical cleaning agents), disabled 6 months ago } Current complaint: Can not afford copays, primary doctor encouraged this visit with MTM today } COPD meds: Tiotropium inh 18mcg daily, fluticasone/salmeterol mcg disc 1 puff twice daily, albuterol inh 2 puffs q4 PRN, oxygen continuous at 3 liters } Spirometry: FEV 1 42% predicted, FEV1/FVC<0.60 } Comorbid conditions: pulmonary hypertension, obstructive sleep apnea, heart failure, hypertension, hyperlipidemia, depression, GERD, allergies, diabetes, fibromyalgia, obesity } Smoking: 0.5 packs/day for 20 years, currently smoking 10 cigarettes per day, currently in stressful situation with needing to move to a different apartment } Vaccinations: not received influenza vaccine this year, received pneumoccal vaccine 13
14 } Avoid risk factors: Tobacco Cessation Avoid air pollution Reduce occupational exposure } Immunizations } Pulmonary Rehabilitation } Physical Activity } Pharmacotherapy } Supplemental Oxygen Therapy } Surgical treatments Lung transplantation, lung volume reduction surgery Forced Expiratory Volume in 1 Second (FEV 1 ) [% of Value at Age 25] Smoke regularly and susceptible to 50 its effects Disability 25 Death * * Age (Years) Never smoked or not susceptible to smoke Stopped at age 45 Stopped at age 65 * Death due to irreversible chronic obstructive lung disease. Reprinted with permission from Fletcher C, Peto R. The natural history of chronic airflow obstruction. Br Med J. 1977;1(6077): } Ask patients about smoking to identify all candidates } Advise all tobacco users to quit } Assess the desire of the patient to quit } Assist in motivation and treatment } Arrange for follow-up and further smoking cessation monitoring Treating Tobacco Use and Dependence: 2008 Update Accessed 8/17/
15 } First-line Therapies Bupropion (Zyban, Wellbutrin ) Varenicline (Chantix ) Nicotine Replacement Therapies (NRT) Nicotine Patch (Nicoderm, Nicotrol, Habitrol, ProStep ) Nicotine Gum (Nicorette ) Nicotine Nasal Spray (Nicotrol NS ) Nicotine Inhaler (Nicotrol Inhaler ) Nicotine Lozenge (Commit Lozenge ) } Second-line Therapies Clonidine Nortriptyline } Combination Therapy Patch + ad lib NRT Patch + Buproprion SR Patch + nortriptyline Patch + Inhaler Patch + second generation antidepressant Treating Tobacco Use and Dependence:2008 Update Accessed 8/17/2012 } Initial visit reviewed inhaler technique, influenza vaccine given } Smoking cessation: Ready to stop smoking by 3rd visit (wants to live longer): Varenicline initated Developed strategies for stress: riding scooter, play with Ossy, chewing gum } 3 week follow-up smoking 1 cigarette per day } 4 week, 2 month, 6 month, 1 year post quit date not smoking!! } Chief complaints: coughing for one month, almost went to ER last night due to increasing shortness of breathe, been watching grandchildren and was exposed to pertussis } COPD: Diagnosed Quit smoking 2007 with 1 pack per day smoking history for many years. } COPD Medication: Albuterol inhaler 2 puffs every 6 hours PRN } Vaccinations: Tdap 2/2012, 10/2011 Influenza 15
16 } Comorbid conditions: Chronic pain, fibromyalgia, IBS, history of breast cancer, depression, anxiety, hypothyroidism, psoriasis } Spirometery: today FEV 1 64% predicted, FEV1/ FVC<0. 60; 2006 FEV 1 62% predicted } Xray=normal } Nasal swab: Negative for B. pertussis and B. parapertussis by PCR } Bronchodilators Beta 2 -agonists Anticholinergics Methylxanthines (not recommended as 1 st line) } Corticosteroids } Phosphodiesterase-4 inhibitors } Alpha-1 antitrypsin therapy } Antibiotics Not recommended except for treatment of infectious exacerbations and other bacterial infections } Mucolytic agents (Acetylcysteine/Mucomyst): Patients with viscous sputum may benefit from Overall benefits are very small Medication Class Short-Acting (SA) Anticholinergics Beta 2 -agonists Combination of beta 2 -agonist and anticholinergic Ipratropium (Atrovent HFA, nebs) Albuterol HFA (Proair, Ventolin, Proventil) Albuterol nebs, inhal soln Levalbuterol (Xopenex HFA, nebs) Pirbuterol (Maxair) Ipratropium+albuterol (Combivent, Duoneb, nebs) Long-Acting (LA) Tiotropium (Spiriva) Aclidinium (Tudorza Pressair) Salmeterol (Serevent) Formoterol (Foradil / Perforomist) Indacaterol (Arcapta Neohaler) Arformoterol (Brovana) None available 16
17 } Inhaled Corticosteroids (ICS) o Long term monotherapy not recommended o Beclomethasone, Budesonide, and Fluticasone o FEV 1 <60% predicted, symptoms, lung function, quality of life and frequency of exacerbations o Increases risk of pneumonia } Combination: ICS + Long Acting beta 2 -agonist o Fluticasone and Salmeterol (Advair ) o Budesonide and Formoterol (Symbicort ) More effective than single agents alone Increases risk of pneumonia } Systemic (long term treatment not recommended) } Addition of a long-acting beta 2 -agonist/inhaled glucorticosteroid combination to an anticholinergic (tiotropium) appears to provide additional benefits. } UPLIFT Trial: Addition of tiotropium in Stage II-III COPD (2987 vs 3006 controls); 72% using LABAs and/or ICS; 4 year study } Results Tiotropium therapy associated with improvements in lung function, quality of life, and exacerbations during a 4-year period but did not significantly reduce the rate of decline in FEV 1. Global Strategy for Diagnosis, Management and Prevention of COPD, (assessed 8/18/12) Tashkin DP, Celli B et al. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. NEJM 2008; 359: } Phophodiesterase-4 Enzyme Inhibitor } Anti-inflammatory and bronchodilator activity } Reduce exacerbations for patients with chronic bronchitis, patients with FEV 1 < 50% of predicted and frequent exacerbations that are not adequately controlled by long acting bronchodilators } Dosing: 500mg once daily } Monitoring/Side effects GI side effects: diarrhea, nausea, abdominal pain CNS: Insomnia, depression and/or suicidal thoughts or behavior Weight loss Drug interactions with CYP3A4 drugs } Two, 12 month trials, roflumilast rate of moderate or severe exacerbations by 15% & 18% Product information for Daliresp. Forest Pharmaceuticals, Inc. St. Louis, MO Feb
18 } Spirometry is required to make a clinical diagnosis of COPD Classification of Severity of Airflow Limitation in COPD (Based on Post-Bronchodilator FEV1) GOLD 1 Mild FEV1 80% predicted GOLD 2 Moderate 50% FEV1 < 80% predicted GOLD 3 Severe 30% FEV1 < 50% predicted GOLD 4 Very Severe FEV1 < 30% predicted All conditions are in patients with FEV1/FVC < 0.7 Global Strategy for Diagnosis, Management and Prevention of COPD, (assessed 8/18/12) Patient Characteristic Spirometric Classification A B C D Low Risk Less Symptoms Low Risk More Symptoms High Risk Less Symptoms High Risk More Symptoms When assessing risk, choose the highest risk according to GOLD grade or exacerbation history Exacerbations per year mmrc CAT GOLD < 10 GOLD > 2 10 GOLD 3-4 > < 10 GOLD 3-4 > 2 > 2 Global Strategy for Diagnosis, Management and Prevention of COPD, (assessed 8/18/12) 10 COPD Assessment Test (CAT): An 8-item measure of health status impairment in COPD ( No permission to use in the USA. Modified Medical Research Counsel (mmrc) Dyspnea Questionnaire Dennis E. Doherty, MD, FCCP, Mark H. Belfer, DO, FAAFP, Stephen A. Brunton, MD Leonard Fromer, MD, Charlene M. Morris, MPAS, PA-C, Thomas C. Snader, PharmD, CGP, FASCP. Chronic Obstructive Pulmonary Disease: Consensus Recommendations for Early Diagnosis and Treatment. Journal of Family Practice, November,
19 Patient First Choice Second Choice Alternative A (Medication in each box are not necessarily in order of preference) SA anticholinergic PRN or SA beta2-agonist PRN LA anticholinergic or LA beta2-agonist or SA beta2-agonist/sa anticholinergic Theophylline B C D LA anticholinergic or LA beta2-agonist ICS + LA beta2-agonist or LA anticholinergic ICS + LA beta2-agonist or LA anticholinergic LA anticholinergic and LA beta2- agoinst LA anticholinergic and LA beta2- agonist ICS + LA anticholinergic or ICS + LA beta2-agonist + LA anticholinergic or ICS + LA beta2-agonist + PDE-4 inh. or LA anticholinergic + LA beta2- agonist or LA anticholinergic + PDE-4 inh. SA beta2 agonist and/or SA anticholinergic Theophylline PDE-4 Inh. SA beta2-agonist and/or SA anticholinergic Theophylline Carbocysteine SA beta2-agonist and/or SA anticholinergic Theophylline Adapted from Global Strategy for Diagnosis, Management and Prevention of COPD, (assessed 8/18/12) } Tiotropium inhaler initiated, reviewed inhaler technique, MD gave azithromycin. } 1 month later: reports breathing much better. Did not realize she had so much trouble breathing going up the stairs and how much things are improved. } Got a rash and went to the ER, thought it was the tiotropium. Started taking it every day for 1 week and then off for one week. } Actions: Reviewed COPD Action plan, inhaler technique, pneumoccol vaccination given. Recommend tiotropium daily. } Status/Post hospitalization for left upper lobe pneumonia, COPD exacerbation } Comorbid conditions: Rheumatoid arthritis steroid dependent, hyponatremia, Stage III pressure ulcer right heel, macrocytic anemia, weakness, dehydration, A fib, BPH, RLS } COPD Medications: Flucticasone/salmeterol disc 500/50 mg 1 inh twice daily, albuterol nebs 0.083% four times daily, albuterol inhaler 2 puffs q6 prn, tiotropium 1capsule inh once a day, prednisone taper down to 5mg once a day, oxygen 2 liters } Married, lives at home with wife. Discharged to skilled nursing facility. Smoker, currently on nicotine patch. Alcohol occasionally drinks. Vaccinations: pneumoccocal 2008, annual influenza 19
20 Assess and Educate on Inhaler Technique in Every Patient! Wieshammer, S., & Dreyhaupt, J. (2008). Dry powder inhalers: Which factors determine the frequency of handling errors. Respiration 2008; 75: Lareau SC and Hodder R. Teaching Inhaler use in chronic obstructive pulmonary disease patients. American Academy of Nurse Practitioners 2012; 24: } } Regimen including a long-acting bronchodilator and scheduled administration of short-acting bronchodilator Scheduled ipratroptium + tiotropium Scheduled albuterol + salmeterol/formoterol Regimen containing two corticosteroids Salmeterol/fluticasone inhaler + oral prednisone Budesonide nebs + oral dexamethasone Salmeterol/fluticasone + budesonide nebs COPD Onset in mid-life Symptoms slowly progressive Long smoking history Mono therapy: LABA/ Anticholinergic Do not use ICS alone ASTHMA Onset early in life (often childhood) Symptoms worse at night/early morning Symptoms vary from day to day Allergy, rhinitis, and/or eczema also present Family history of asthma Mono therapy: ICS Do not use LABA alone Vaccination: Influenza + Pneumovax Smoking Cessation Proper Inhaler Technique COPD/Asthma Action Plan 20
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