COPD Breathing Made Easier Catherine E. Cooke, PharmD, BCPS, PAHM Independent Consultant, PosiHleath Clinical Associate Professor, University of Maryland School of Pharmacy This program has been brought to you by PharmCon PharmCon is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
Learning Objectives Describe COPD and the symptoms generally associated with it. Provide an update on the efficacy, safety, and role of available treatments in the management of COPD. Recommend a treatment regimen for a patient with COPD. Describe the pharmacist s role and the importance of adherence to therapy for patients with COPD.
Patient Case: CP 51 year-old woman with chronic cough w/ sputum production comes in complaining of SOB w/ exertion. CP states that she can t carry the laundry up the steps without stopping half-way through to catch her breath. Smoking History: She currently smokes 1 ppd (x 35 years) Diagnosis: COPD What treatment would you recommend at this time? A. No drug therapy is necessary since none of the treatments decrease mortality B. Short-acting inhaled bronchodilator C. Long-acting inhaled bronchodilator D. Corticosteroids
Overview Definition of COPD Risk Factors Pathophysiology Treatment Interventions to assist patients with COPD Patient Case Review
Definition of COPD Normal Damage + Cholinergic Tone
COPD is the 4th Leading Cause of Death in the US About 120,000 deaths in 2000 US COPD prevalence 5.9% (~ 10 million adults) Approximately 70% of COPD patients were < 65 years of age Women outnumber men in deaths attributable to COPD
COPD Defining Characteristics Chronic bronchitis Clinical diagnosis Mucus-producing cough most days of the month Emphysema Pathologic diagnosis Irreversible enlargement of air spaces distal to terminal bronchioles Alveolar destruction Spirometric diagnostic criteria Reduced forced expiratory volume in 1 second (FEV 1 < 80%) Reduced ratio of FEV 1 to FVC (FEV 1 /FVC; < 70%)
Risk Factors Primary: cigarette smoking History of tobacco use present in 80%-90% of cases Secondary α 1-protease inhibitor deficiency Occurs in 1%-2% of COPD population Occupational/environmental exposures Low birth weight in the presence of viral infection History of severe childhood respiratory infection
Clinical Features Initially: cough, with or without sputum Increased symptoms with respiratory tract infections Progressive shortness of breath with activity Ultimately: inability to perform activities of daily living, increasing episodes of symptom deterioration and exacerbations End-stage findings: respiratory insufficiency, pulmonary hypertension, cor pulmonale
Pathophysiology of COPD Airflow obstruction as a result of: Bronchoconstriction Principally mediated by cholinergic tone Adrenergic tone also plays a role Improves with bronchodilators Airway and parenchymal inflammation Not effectively treated Increased mucus secretion Not effectively treated Structural changes Not effectively treated
Making the Diagnosis Initial diagnosis based on clinical presentation Symptoms Cough, dyspnea, respiratory infections, lifestyle limitations Acute vs. chronic Smoking History Age (>40 years) Clinical diagnosis confirmed by spirometry
Spirometry Lung function reported as percent of predicted values for a normal population Terminology FEV 1 = forced expiratory volume in 1 second FVC = forced vital capacity FEV 1 /FVC is diagnostic of COPD when < 70%
Spirometry: Volume/Time Curve FEV 1 FVC FEV 1 / FVC Normal 4.15 5.2 > 80% COPD 2.35 3.9 < 70% 1 2 FEV 1 Liters 3 4 FEV 1 COPD FVC 5 Normal FVC 1 2 3 4 5 6 Seconds
Management Objectives Prevent disease progression; reduce mortality Relieve symptoms Improve health status, exercise tolerance Prevent and treat exacerbations, complications Minimize side effects from treatment
COPD Guidelines First-line pharmacologic maintenance therapy ATS Anticholinergics GOLD Long-acting anticholinergic or β-adrenergic bronchodilators Second-line pharmacologic maintenance therapy Combination therapy (2 or more bronchodilators, including an anticholinergic) Combination therapy (2 or more bronchodilators) Role of inhaled steroids Routine use not recommended Only symptomatic patients with FEV 1 < 50% predicted and repeated exacerbations
Step therapy for patients with COPD
Nonpharmacologic Therapy Education Smoking cessation Pulmonary rehabilitation Influenza/pneumococcal vaccinations Nutrition
Smoking Cessation Single most effective way to improve clinical outcomes in patients at all stages, from asymptomatic to severe Slows decline in FEV 1 With early smoking cessation, rate of FEV 1 decline can return to that of nonsmokers 3 or 4 quitting attempts may be necessary for success
Age-Related Decline in FEV 1 Is Accelerated in Susceptible Smokers FEV 1 (% of value at age 25 years) 100 75 50 25 0 Disability Death 25 50 75 Age (years) Never smoked or not susceptible to smoke Stopped at 45 years Stopped at 65 years Smoked regularly and susceptible to its effects FEV 1 = forced expiratory volume in 1 second. Adapted with permission from Fletcher C, Peto R. BMJ. 1977;1:1645-1648. www.bmj.com search January 2004
Pharmacologic Therapy Rescue therapy Occasional mild symptoms As-needed basis Maintenance therapy Objectives for patients with recurrent or worsening symptoms: Reduce dyspnea Improve quality of life Reduce need for rescue therapy Reduce exacerbation frequency
Maintenance Therapy in COPD Only smoking cessation has been shown to definitively affect rate of lung function decline in COPD Pharmacologic treatment can improve and prevent symptoms, reduce frequency and severity of exacerbations, improve health status, and improve exercise tolerance No medications have yet been shown to modify the long-term decline in lung function
Management of Acute Exacerbations Systemic steroids Typically for 1 2 weeks Antibiotics Particularly if increased dyspnea, increased sputum and increased purulence Empiric use of narrow-spectrum antibiotics reduces duration, increases PEFR Short-acting bronchodilators Oxygen (if hypoxemic) Ventilatory support
Bronchodilators The Recommended First-Line Treatment Anticholinergics Long-acting Short-acting β 2 -agonists Long-acting Short-acting Combination agents 2 Bronchodilators Bronchodilator and corticosteroid Theophylline
Bronchodilators: Summary Characteristics Agent Use Mechanism of Action Adverse Drug Reactions # Doses/day Anticholinergics 1 (ipratropium, tiotropium) Maintenance Blocks bronchoconstrictive action of acetylcholine Dry mouth, headache, nervousness, nausea, dizziness 1-4x/day Short-acting β 2 -agonists 2 (albuterol) Rescue Relaxes bronchial smooth muscle Tachycardia, palpitations, chest pain, tremor, nervousness Up to 4x/day Long-acting β 2 -agonists 3,4 (salmeterol, formoterol) Maintenance Relaxes bronchial smooth muscle Tachycardia, palpitations, immediate hypersensitivity reactions, headache, tremor, nervousness 1-2x/day
Bronchodilators: Summary Characteristics Agent Use Mechanism of Action Adverse Drug Reactions Dosing Anticholinergic + short-acting β 2 -agonist 1 (combination ipratropium bromide + albuterol sulfate) Maintenance Reduces bronchospasm through 2 pathways: Anticholinergic pathway Sympathomimetic pathway Same as individual components; no increase in risk with combination therapy 4x/day Theophylline 2 Maintenance Smooth muscle relaxation and suppression of bronchospastic response to stimuli Nausea, vomiting, diarrhea, headache, insomnia, restlessness, cardiac arrhythmias, intractable seizures Dose and frequency of administration depend on formulation. titrate dose to serum concentration 5-14 μg/ml
Therapy Compliance Lack of patient adherence becomes more significant when: Daily therapy is required Multiple products are required Evidence indicates higher compliance with a less frequent dosing regimen 1-3
Improving care of patients with COPD ASSIST with smoking cessation
Improving care of patients with COPD ENSURE up-to-date vaccinations
Improving care of patients with COPD CHECK inhaler technique
Improving care of patients with COPD DETERMINE NON-ADHERENCE (including treatment failures) Refill too soon Refill much later than expected Erratic refill patterns
Patient Case: CP 51 year-old woman with chronic cough w/ sputum production comes in complaining of SOB w/ exertion. CP states that she can t carry the laundry up the steps without stopping half-way through to catch her breath. Smoking History: She currently smokes 1 ppd (x 35 years) Diagnosis: COPD (FEV 1 < 60% predicted) What treatment would you recommend at this time? A. No drug therapy is necessary since none of the treatments decrease mortality B. Short-acting bronchodilator C. Long-acting inhaled bronchodilator D. Corticosteroids
Summary Focus on interventions known to decrease worsening of lung function Smoking Cessation Treatment goal is to improve quality-of-life Use therapies when necessary to improve activities of daily living/function Proper inhaler technique/use of devices Preventive therapies - vaccinations