View
3
Download
0
Category
Preview:
Citation preview
Inhaler Use in Older COPD Patients
Amber M. Hutchison, PharmD, BCPSAssistant Clinical ProfessorAssistant Clinical Professor
Auburn University Harrison School of Pharmacy
DisclosuresDisclosures
• Neither I, nor my spouse, haveNeither I, nor my spouse, have relationships with pharmaceutical companies, biomedical device manufacturers, or other commercial companies whose products or
i l t d t th bj tservices are related to the subject matter of this presentation.
ObjectivesObjectives• Discuss guideline recommendations for
f h i b itreatment of chronic obstructive pulmonary disease (COPD)
• Demonstrate the burden of COPD management in elderly patients
• Define age-related physical changes associated with long-term COPD in grelationship to medication management
• Recommend appropriate medication therapy adjustments as needed for long-py j gterm COPD management to accommodate age-related physical changes
COPD DefinitionCOPD Definition
• Chronic obstructive pulmonaryChronic obstructive pulmonary disease (COPD)– Preventable and treatable– Characterized by persistent airflow
limitation that is usually iprogressive
– Associated with an enhanced chronic inflammatory response inchronic inflammatory response in the airways and the lung to noxious particles or gases
GOLD Guidelines 2014. www.goldcopd.org
COPD PrevalenceCOPD Prevalence• The direct costs of COPD for the US
has been estimated at $29 5 billionhas been estimated at $29.5 billion• Worldwide COPD is estimated to
become the third leading cause of death in 2020 and fourth leadingdeath in 2020 and fourth leading cause of death in 2030
• In the United States:– In 2011, 6.5% of the US population had
COPD– In 2010, there were 133,575 deaths
caused by COPD– Overall, death rates for COPD have not
declined
GOLD Guidelines 2014. www.goldcopd.orgFord ES. CHEST. 2013;144(1):284‐305.
COPD PrevalenceCOPD Prevalence
Age Adjusted Prevalence of COPD in
Ford ES. CHEST. 2013;144(1):284‐305.
Age Adjusted Prevalence of COPD in adults >25 years of age in 2011
COPD Prevalence
Age Adjusted Death-rates (per 100 000) of COPD in adults >25 years
Ford ES. CHEST. 2013;144(1):284‐305.
100,000) of COPD in adults 25 years of age between 1999-2000
COPD Prevalence
Age Adjusted Death-rates (per 100 000) of COPD in adults >25 years
Ford ES. CHEST. 2013;144(1):284‐305.
100,000) of COPD in adults 25 years of age between 2009-2010
COPD in Older AdultsCOPD in Older Adults• The number of people >60 years
f fof age is expected to rise from 810 million in 2012 to 2 billion in 20502050– People >80 years of age is
expected to increase 4-foldexpected to increase 4 fold• COPD is one of the most
common chronic diseasescommon chronic diseases affecting older adults
Th U it d N tiThe United Nations. http://www.un.org/esa/population/publications/2012PopAgeingDev_Chart/2012PopAgeingandDev_WallChart.pdfValente S. Respiration 2010;80:357-368.
Risk Factors for COPDD l t & P iDevelopment & Progression• Cigarette smokingg g• Genetic factors
– Alpha-1 antitripsyn deficiency• Age• Lung growth and development
E t ti l• Exposure to particles• Socioeconomic status—questionable• Asthma/bronchial hyperreactivity• Asthma/bronchial hyperreactivity• Chronic bronchitis• Infections• Infections
GOLD Guidelines 2014. www.goldcopd.org
COPD Symptoms and Di iDiagnosis
Symptoms• Symptoms– Dyspnea– Cough– Sputum production– Wheezing and chest tightness
• Diagnosis– Spirometry demonstrating post-
bronchodilator FEV1/FVC <0.70
GOLD Guidelines 2014. www.goldcopd.org
COPD AssessmentCOPD Assessment
COPD AssessmentCOPD Assessment• Goals of assessment
D i i f h di– Determine severity of the disease– Impact on health status
Determine risk of future events– Determine risk of future events– Used to guide therapy
• Disease characteristicsDisease characteristics considered– Spirometryp y– Patient symptoms– Exacerbation risk– Comorbidities
GOLD Guidelines 2014. www.goldcopd.org
Normal SpirometryNormal Spirometry5
4(li
ters
) FVC = 5L
2
3
olum
e (
FEV1 = 4L
1
2
Vo
FEV1 /FVC= 0.8
1 2 3 4 5 6
Time (seconds)
Spirometry in Ob i DiObstructive Disease5
4(li
ters
)
2
3
olum
e (
FVC = 2.9L
1
2
Vo
FEV1 = 1.5L FEV1 /FVC= 0.57
1 2 3 4 5 6
Time (seconds)
COPD AssessmentCOPD Assessment
• SpirometrySpirometry– Based on post-bronchodilator FEV1
GOLD Classification Severity 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
GOLD Guidelines 2014. www.goldcopd.org
COPD AssessmentCOPD Assessment• Patient symptoms
– COPD Assessment Test (CAT)COPD Assessment Test (CAT)• 8 items• Score ranges 0-40• <10 means less symptoms >10 means• <10 means less symptoms, >10 means
more symptoms– COPD Control Questionnaire (CCQ)
• 10 items self administered• 10 items—self administered• <1 more symptoms, >1 less symptoms
– Modified British Medical Research C il Q ti i ( MRC)Council Questionnaire (mMRC)
• 5 grades—score of 0-4• <2 less symptoms, >2 more symptoms
GOLD Guidelines 2014. www.goldcopd.org
COPD AssessmentCOPD Assessment
• Exacerbation risk assessmentExacerbation risk assessment– Exacerbation
• Acute event• Acute event • Characterized by worsening of
patient’s respiratory symptoms • Leads to change in medications
– Frequent exacerbations are more than 2 per year
GOLD Guidelines 2014. www.goldcopd.org
COPD AssessmentCOPD Assessment
• Exacerbation risk assessmentExacerbation risk assessment– High risk:
• >2 exacerbations per year• >2 exacerbations per year• >1 exacerbation leading to hospital
admission– Lower risk: 1 exacerbation per
year (not leading to hospital admission)
GOLD Guidelines 2014. www.goldcopd.org
COPD AssessmentCOPD Assessment
• ComorbiditiesComorbidities– All comorbidities should be
evaluated at each visit and treatedevaluated at each visit and treated according to guidelines
GOLD Guidelines 2014. www.goldcopd.org
COPD AssessmentCombinedCombined
Exacerbation History
GOLD Spirometry
C D >2/year OR>1 leading to admit
3-4
A B
to admit
0-1 exacerbation1-2 A B
CAT < 10 CAT > 10
exacerbation/year
CAT < 10 CAT > 10
Symptoms
mMRC <2 mMRC > 2mMRC 2 mMRC > 2
BreathlessnessGOLD Guidelines 2014. www.goldcopd.org
Method of AssessmentMethod of Assessment
• 1 Assess symptoms with CAT1. Assess symptoms with CAT or mMRC
• 2 Assess risk of exacerbations• 2. Assess risk of exacerbations– A. Evaluate spirometry
B A b f– B. Assess number of exacerbations within the previous 12 months12 months
– C. Assess if patient has been hospitalized for exacerbationhospitalized for exacerbation
Patient CasePatient Case
• MS is a 67 year old female whoMS is a 67 year old female who has had COPD for 9 years. During an MTM visit, you ask g yseveral questions to assess her COPD. Her CAT score is 16. FEV t l t tFEV1 at last measurement was 35%. She had one COPD exacerbation 8 months ago andexacerbation 8 months ago and was admitted to the local hospital for 5 dayshospital for 5 days.
Patient CasePatient Case
• What group would you place MSWhat group would you place MS into?
• A• A• B• C• D
Patient CasePatient Case
• SN is a 72 year old male withSN is a 72 year old male with COPD. As a part of his outpatient visit you need tooutpatient visit, you need to assess his COPD. His mMRCscore is 2 He had one COPDscore is 2. He had one COPD exacerbation 3 months ago which was treated outpatientwhich was treated outpatient. His FEV1 at last measurement was 52%was 52%.
Patient CasePatient Case
• What group would you place SNWhat group would you place SN into?
• A• A• B• C• D
COPD Assessment C bi dCombined
PtCategory
Character Spriometry Exacer/ year
CAT mMRC
A Low risk, Less
FEV1>50% <1 <10 <2Less symptoms
B Low risk,More
FEV1>50% <1 >10 >2More symptoms
C High risk,Less
FEV1<50% >2 <10 <2
symptomsD High risk,
More FEV1<50% >2 >10 >2
symptoms
GOLD Guidelines 2014. www.goldcopd.org
COPD TreatmentCOPD Treatment
COPD TreatmentCOPD Treatment
• Pharmacologic treatment g– No agent has been shown to decrease
mortality for COPD patientsReduces COPD symptoms frequency– Reduces COPD symptoms, frequency of exacerbations, and improve health status
• Smoking cessation – Slows disease progression
• Oxygen therapy• Oxygen therapy– Increases survival in patients with
severe resting hypoxemia
GOLD Guidelines 2014. www.goldcopd.org
COPD TreatmentC A tCommon Agents
• Inhalers • Oral agentsInhalers– Beta agonists
• Short vs. long
Oral agents– Methylxanthines
• Theophyllineacting
– Anticholinergics• Short vs. long
• Aminophylline– Phosphodiesterate-4
inhibitor (PDE4 Short vs. long acting
– CorticosteroidsC bi ti
inhibitor)• Roflumilast
(Daliresp®)– Combination
inhalers
GOLD Guidelines 2014. www.goldcopd.org
COPD TreatmentI h lInhalers
• Beta2-agonists2 g– SABA: Short-acting beta agonists
• Albuterol, levalbuterol– LABA: Long-acting beta agonistsLABA: Long acting beta agonists
• Formoterol, aformoterol, indacaterol, salmterol
• Anticholinergics (muscarinic agents)g ( g )– SAAC: Short-acting anticholingerics
• Ipratropium– LAAC: Long-acting anticholinergicsLAAC: Long acting anticholinergics
• Aclidinium, tiotropium• Corticosteroids
ICS inhaled corticosteroid– ICS—inhaled corticosteroid
GOLD Guidelines 2014. www.goldcopd.org
COPD TreatmentI h l C bi iInhalers—Combination
• SABA + SAAC– Albuterol + ipratropium
• LABA + LAAC– Vilanterol + umeclidinium (Anoro
Ellipta®)• LABA + ICSLABA + ICS
– Formoterol + budesonide (Symbicort®)– Formoterol + mometasone (Dulera®)– Salmeterol + fluticasone (Advair®)– Vilanterol + fluticasone (Breo Ellipta®)
GOLD Guidelines 2014. www.goldcopd.org
COPD TreatmentCOPD Treatment
• Methods of inhalationMethods of inhalation administration
Metered dose inhalers– Metered dose inhalers– Dry powder inhalers
Nebulizer solutions– Nebulizer solutions
COPD TreatmentCOPD Treatment
• Metered dose inhalerMetered dose inhaler– Medication is administered as
aerosol with propellant– Actuation and inhalation require
coordinationC ith t h l ith• Can use with spacer to help with coordination
– Patient should inhale slowlyPatient should inhale slowly– Priming is required– Shake before use
COPD TreatmentCOPD Treatment
• Dry powder inhalerDry powder inhaler– Multiple forms on the market
• Need to understand mechanics of each– Medication is in powder form
• No propellant– Patient inhalation triggers actuation – Coordination is not necessary
• Spacer cannot be used– Patient should inhale quickly
COPD TreatmentCOPD Treatment
• NebulizersNebulizers– Medication is in liquid form
Device uses compressed air to– Device uses compressed air to aerosolize medication
• Nebulization device is bulky andNebulization device is bulky and requires electricity
• Administration time is prolonged compared to other devices
– No coordination required
Self-CheckSelf Check
• Which method of inhalationWhich method of inhalation requires the least hand-breath coordination?coordination?– Metered dose inhaler
Dry powder inhaler– Dry powder inhaler– Nebulizer
COPD TreatmentS l iSelection
• Bronchodilator medications are central to symptom management
• Inhaled therapy is preferred• Choice of therapy is dependent on
availability and patient response• Long acting inhaled bronchodilators• Long-acting inhaled bronchodilators
are convenient and more effective for maintained symptom relief
• Combination products may improve efficacy and decrease risk of side effectseffects
GOLD Guidelines 2014. www.goldcopd.org
COPD TreatmentS l iSelection
• Long acting beta2-agonists andLong acting beta2 agonists and anticholinegrics are preferred over short term
• Long-term use of ICS alone is not recommended
ff– Less effective than the combination of ICS + LABA
• Long-term monotherapy of oral• Long-term monotherapy of oral corticosteroids is not recommended
GOLD Guidelines 2014. www.goldcopd.org
COPD Treatment SelectionGroup First Line Alternative Other
A SABA or SAAC
LAAC or LABA or
SABA+SAAC
Theophylline
B LAAC LABA+LAAC SABA d/B LAAC orLABA
LABA+LAAC SABA and/or SAAC or
TheophyllineC ICS+LABA LABA+LAAC or SABA and/orC ICS+LABA
or LAACLABA+LAAC or
LAAC+PDE4 inhibitor or
LABA+PDE4 inhibitor
SABA and/or SAAC
Theophylline
D ICS+LABA and/or LAAC
ICS+LABA+LAACor
ICS+LABA+PDE4 i hibit
Carbocysteine
SABA and/or SAACinhibitor
OrLAAC+LABA
Or
SAAC
Theophylline
OrLAAC+PDE4 inhibitor
GOLD Guidelines 2014. www.goldcopd.org
Patient CaseEarlier we decided MS’s group• Earlier, we decided MS s group was________.
• MS is currently on scheduledMS is currently on scheduled formoterol and PRN albuterol. She is experiencing symptoms which are limiting her quality of lifeare limiting her quality of life.
• What is your recommendation?– Change formoterol to nebulizedChange formoterol to nebulized
albuterol– Change formoterol to mometasone
Change formoterol to formoterol plus– Change formoterol to formoterol plus budesonide
– Change formoterol to formoterol plus b d id d ti t ibudesonide and tiotropium
Patient CaseS• Earlier, we decided SN’s group
was________.SN i tl lb t l• SN is currently on albuterol as needed. As you have discovered, he is having increased dyspneahe is having increased dyspnea. What is your recommendation?– Discontinue albuterol and start
tiotropium– Continue albuterol and start
tiotropiumtiotropium– Discontinue albuterol and start
fluticasone– Continue albuterol and start
mometasone and formoterol
Application to Older Adults
Treatment of COPD in Old Ad lOlder Adult
• Considerations for pharmacistsConsiderations for pharmacists– Age-related changes
Peak inspiratory flow– Peak inspiratory flow– Patient education
Smoking cessation– Smoking cessation– Immunizations
Age Related Changes• Physical changes
– Manual dexterityManual dexterity– Visual changes– Age is inversely related to extremity
l t th i t lmuscle strength, respiratory muscle strength, and pulmonary function
• Cognitive changesg g– Patients with a Mini Mental Status
Exam score of less than 23 out of 30 are unlikely to learn and retainare unlikely to learn and retain correct MDI technique
Vincken W. Prim Care Resp J. 2010;19(1):10‐20.Valente S. Respiration. 2010;80:357‐368.
Peak Inspiratory FlowPeak Inspiratory Flow
• Inhalers require a minimumInhalers require a minimum peak inspiratory flow
• Optimal peak inspiratory flowsOptimal peak inspiratory flows– MDI—minimum 25 L/min– DPIDPI
• Turbuhaler—minimum 60 L/min• HandiHaler—minimum 20 L/min• Diskus—minimum 30 L/min
– Nebulizer—no peak inspiratory flow neededflow needed
Patient Education• Progression of disease
Not curable and progressive– Not curable and progressive– Medical therapy will not be
stepped downstepped down• Medication counseling
– Role of medicationsRole of medications• Rescue medication vs maintenance
medication– Inhaler devices
• Ensure correct use at each visit• Demonstrate technique for patient• Demonstrate technique for patient• Use teach-back approach
Smoking CessationSmoking Cessation• Has the greatest impact on the g p
progression of COPD• In 2011, 39% of the 15 million ,
adults with COPD continued to smoke
• Recommended for all GOLD categories
• Most trials have been done in middle-aged populations
GOLD Guidelines 2014. www.goldcopd.orgFord ES. CHEST. 2013;144(1):284‐305.
Smoking Cessation
at a
ge 2
5) o
f val
ue a
FE
V1
(%g
func
tion
Lung function vs. age and the relationship
AgeLun
g g pbetween smoking and lung function decline
Parkes G. BMJ. 2008;336(7644):598‐600
Smoking Cessation
rs)
EV
1 (L
iter
hodi
lato
r Fos
t-bro
nch
Aver
age
po
Loss of lung function over 11 years based on smoking status
Time (years)A
based on smoking statusTashkin DP. Resp Med. 2009;103:963‐974.Anthonisen NR. Am J Respir Crit Care Med. 2002;166(5):675‐679.
Smoking CessationSmoking Cessation• Counseling delivered by healthcare
f i l i it tprofessionals increases quit rates• Brief strategies to help the patient
willing to quit (the 5 A’s):willing to quit (the 5 As):– Ask—identify all tobacco users– Advise—strongly urge all tobacco users
t itto quit– Assess—determine willingness to make
a quit attemptq p– Assist—aid the patient in quitting– Arrange—schedule follow-up contact
GOLD Guidelines 2014. www.goldcopd.orgJAMA. 2000;283(24):3244‐3254.
Smoking CessationSmoking Cessation• Products available for smoking
cessation– OTC
• Nicotine replacement in the form of patches, gum, or lozenges
– Prescription onlyPrescription only• Nicotine replacement in the form of
inhaler or nasal sprayV i li (Ch ti ®)• Varenicline (Chantix®)
• Buproprion (Zyban®)
GOLD Guidelines 2014. www.goldcopd.orgJAMA. 2000;283(24):3244‐3254. Nicotine. In: Lexi‐Comp Online [AUHSOP Intranet].
Self-CheckSelf Check
• Which of the following is FALSEWhich of the following is FALSE regarding smoking cessation?
It is recommended for all stages of– It is recommended for all stages of COPD
– Counseling by healthcareCounseling by healthcare professionals increases likelihood of quittingq g
– Smoking cessation stops the progression of COPD
ImmunizationsImmunizations
• Review the immunization history yfor all patients– Can be done in community setting,
clinic setting or hospital settingclinic setting, or hospital setting– Follow guidelines from the Centers
for Disease Control Advisory Committee on ImmunizationCommittee on Immunization Practices (CDC ACIP)
– Guidelines are released yearly• Available from:
– http://www.cdc.gov/vaccines/schedules/hcp/adult htmles/hcp/adult.html
Immunizations• Influenza vaccination
– Inactivated influenza vaccine (IIV)– Inactivated influenza vaccine (IIV) recommended yearly
– 18-64 years of age may receive intradermal or intramuscular IIV
– >65 years of age may receive the standard IIV or the high-dose IIVstandard IIV or the high dose IIV
• Benefits– Reduces exacerbationsReduces exacerbations– Reduces influenza infections– Decreases risk of death
GOLD Guidelines 2014. www.goldcopd.orgCDC ACIP 2014 Adult Immunization schedule. http://www.cdc.gov/vaccines/schedules/downloads/adult/adult‐combined‐schedule.pdf
Immunizations• Pneumococcal vaccination• Pneumococcal vaccination
– All patients >65 should receive one dose of the pneumococcal polysaccharide vaccine (PPSV23)(PPSV23)
– COPD patients 19-64 years of age should receive PPSV23
– Patients should be revaccinated after age at e ts s ou d be e acc ated a te age65 if 5 years has passed since last vaccination
• Benefits– Reduces community acquired pneumonia
caused by pneumococcus– Reduces pneumonia caused by both
d k ti l fpneumococcus and unknown etiology for COPD patient <65 years of age and FEV1<40% predicted
GOLD Guidelines 2014 www goldcopd orgGOLD Guidelines 2014. www.goldcopd.orgCDC ACIP 2014 Adult Immunization schedule. http://www.cdc.gov/vaccines/schedules/downloads/adult/adult‐combined‐schedule.pdfSehatzadeh S. Ont Health Technol Assess Ser [Internet]. Available from: www.hqontario.ca/en/mas/tech/pdfs/2012/rev_COPD_Vaccinations_March.pdf
Patient CasePatient Case
• WE is a 74 year old female patientWE is a 74 year old female patient with COPD. Upon reviewing her charts, you find out she received , yher influenza vaccine October of last year and a pneumococcal y pvaccine when she was 67.
• What are your recommendations yfor vaccination?
Patient CasePatient Case
• AP is a 68 year old male patientAP is a 68 year old male patient with COPD. Upon reviewing his charts, you find out he received , yher influenza vaccine December of last year. He received a ypneumococcal vaccine when he was 64.
• What are your recommendations for vaccination?
Potential Solutions for Old P iOlder Patients
Problem SolutionRequires hand-breath coordination
Use a spacer or nebulizer
Lacking hand strength or Use a spacer or nebulizerdexterityDifficulty generating adequate peak inspiratory fl
Change DPI to MDIConsider nebulizer
flowPossible cognitive impairment
Have patient demonstrateproper technique at each visit
Patient on multiple inhalers Change inhalers to same administration type (forexample, all DPI)Combine active ingredients ifCombine active ingredients if possible into single inhalersEnsure proper use at each visit
Assessment QuestionsAssessment Questions
• Which method of inhalationWhich method of inhalation requires the most hand-breath coordination?coordination?– Metered dose inhaler
Dry powder inhaler– Dry powder inhaler– Nebulizer
Assessment QuestionsAssessment Questions
• Which therapy has been shownWhich therapy has been shown to increase survival in COPD patients with persistentpatients with persistent hypoxemia?
LABA + LAAC– LABA + LAAC– LABA + ICS
Smoking cessation– Smoking cessation– Oxygen therapy
Assessment QuestionsAssessment Questions
• TRUE or FALSE:TRUE or FALSE:– Smoking cessation is
recommended only for COPDrecommended only for COPD groups C and D.
Recommended