COPD Update. Plus New and Improved Products for Inhaled Therapy. Catherine Bourg Rebitch, PharmD, BCACP Clinical Associate Professor

COPD Update Plus New and Improved Products for Inhaled Therapy Catherine Bourg Rebitch, PharmD, BCACP Clinical Associate Professor

Disclosure The presenter has nothing to disclose concerning possible financial or personal relationships with any entities mentioned in this presentation. 2

Learning Objectives Summarize recommendations from clinical practice guidelines for chronic obstructive pulmonary disease (COPD) Discuss pharmacotherapy options for COPD Understand and demonstrate proper inhaler technique for new inhaled therapies 3

Chronic Obstructive Pulmonary Disease (COPD) Characterized by airflow limitation that is not fully reversible Preventable and treatable Significant extrapulmonary effects contribute to severity Prevalence and mortality have increased over the past 20 years Bourdet SV, Williams DM. Chronic Obstructive Pulmonary Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill 4

COPD Risk Factors Smoking! Environmental factors Host factors Bourdet SV, Williams DM. Chronic Obstructive Pulmonary Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill 5

COPD Symptoms Constant/chronic cough Shortness of breath Inability to breathe easily/take deep breaths Excess mucus production (coughed up as sputum) Wheezing COPD National Action Plan 2017. Centers for Disease Control and Prevention. 6

COPD Prevalence COPD National Action Plan 2017. Centers for Disease Control and Prevention. 7

COPD National Action Plan COPD National Action Plan 2017. Centers for Disease Control and Prevention. 8

Global Initiative for Chronic Obstructive Lung Disease (GOLD) Striving to improve diagnosis, prevention, and management of COPD across the globe. https://goldcopd.org 9

Management of COPD Classification of airflow obstruction Post-bronchodilator FEV 1 Assessment of symptoms mmrc, CAT, CCQ Selection of pharmacotherapy Assessment of symptoms + risk of exacerbations Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. 2019 Edition. 10

Classification Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. 2019 Edition. 11

Symptom Assessment Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. 2017 Edition. 12

Symptom Assessment 13

Pharmacotherapy Selection Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. 2018 Edition. 14

Pharmacotherapy Selection (Initial) 2 moderate exacerbations or 1 leading to hospitalization 0 or 1 moderate exacerbations (not leading to hospital admission) Group C LAMA Group A A Bronchodilator Group D LAMA or LAMA + LABA * or ICS + LABA** Group B A Long Acting Bronchodilator (LABA or LAMA) mmrc 0-1 or CAT <10 mmrc 2 or CAT 10 *Consider if highly symptomatic (e.g. CAT >20) ** Consider if eosinophils 300 Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. 2019 Edition. 15

Management Cycle Review: Symptoms (Dyspnea) Exacerbations Adjust: Escalate Switch inhaler device or molecules De-escalate Assess: Inhaler technique and adherence Non-pharmacological approaches (including pulmonary rehabilitation and selfmanagement education) Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. 2019 Edition. 16

Pharmacotherapy Selection (Follow-up) LABA or LAMA Dyspnea LABA + LAMA Consider switching inhaler device or molecules Investigate (and treat) other causes of dyspnea ** ** LABA + ICS LABA + LAMA + ICS ** Consider de-escalation of ICS or switch if pneumonia, inappropriate original indication or lack or response to ICS Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. 2019 Edition. 17

Pharmacotherapy Selection (Follow-up) Exacerbations LABA or LAMA LABA + LAMA ** ** LABA + ICS Roflumilast FEV 1 < 50% and chronic bronchitis LABA + LAMA + ICS Azithromycin In former smokers ** Consider de-escalation of ICS or switch if pneumonia, inappropriate original indication or lack or response to ICS Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. 2019 Edition. 18

Non-pharmacologic management Smoking Cessation (essential!!) Physical activity as tolerated Flu and pneumococcal vaccination Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. 2019 Edition. 19

Pharmacologic Options Bronchodilators Antimuscarinic drugs Methylxanthines (ex. theophylline- not as commonly used/overall limited evidence) Combination (+ inhaled corticosteroid) Pocket Guide to COPD Diagnosis, Management, and Prevention. A Guide for Health Care Professionals. 2019 Edition. 20

Bronchodilators Short acting beta agonists (SABA) Albuterol Levalbuterol Long acting beta agonists (LABA) Salmeterol Formoterol Olodaterol Indacaterol Proventil HFA, Proair HFA, Proair RespiClick Ventolin HFA Xopenex Serevent Diskus Formoterol Aerolizer Striverdi Respimat Arcapta Neohaler Bourdet SV, Williams DM. Chronic Obstructive Pulmonary Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill 21

Antimuscarinic drugs Short acting antimuscarinic (SAMA) Ipratropium Atrovent MDI Long acting antimuscarinic (LAMA) Tiotropium Aclidinium Umeclidinium Glycopyrrolate Spiriva Handihaler, Spiriva Respimat Tudorza Pressair Incruse Ellipta Seebri Neohaler Bourdet SV, Williams DM. Chronic Obstructive Pulmonary Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill 22

Combinations SABA/SAMA Albuterol + Ipratropium Combivent Respimat LABA/Inhaled corticosteroid [ICS] Salmeterol + fluticasone Formoterol + budesonide Vilanterol + fluticasone LABA/LAMA Indacaterol + glycopyrrolate Vilanterol + umeclidinium Olodaterol + tiotropium Formoterol + glycopyrrolate LABA/LAMA/ICS Vilanterol + umeclidinium + fluticasone Advair MDI, Advair Diskus Symbicort MDI Breo Ellipta Utibron Neohaler Anoro Ellipta Stiolto Respimat Bevespi Aerosphere MDI Trelegy Ellipta Bourdet SV, Williams DM. Chronic Obstructive Pulmonary Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e New York, NY: McGraw-Hill 23

Inhaler Misuse = Big Problems! Observational study (n = 1664 adults) evaluating proper inhaler technique Out of 2288 records, critical mistakes in technique noted in 12% MDI, 35% Diskus and HandiHaler, and 44% Turbuhaler users Inhaler misuse associated with: Older age, lower schooling, and lack of instruction by a healthcare professional Increased risk of hospitalization, ER visits, courses of oral steroids and antibiotics, and poor disease control based on symptom questionnaires Melani AS, Bonavia M, Cilenti V et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respiratory Medicine (2011): 105, 930-38. 24

Show and Tell I will be seated at a table during lunch (now!) with lots of inhaler demos for you to peruse. Please stop by! 45

Summary COPD is chronic, progressive, and causes significant morbidity and mortality. Inhaled therapy is a cornerstone of management, and inhaler technique plays a pivotal role in disease state control. New inhaler devices aim to improve adherence and outcomes through updated drug delivery systems. 46

Questions/Comments? 48