To Inhale or Not to Inhale?

1. To Inhale or Not to Inhale? Sukhjinder Sidhu Interior Health Pharmacy Resident September 13, 2013

2. Learning Objectives • Describe the pathophysiology of COPD • Become familiar with the clinical presentation and how to access severity of COPD • Be able to explain the evidence for treatment of mild COPD • Describe the role of ICS, LABA in management of COPD

3. Our Patient

4. Our Patient

5. Review of Systems

6. Investigations

7. Course in Hospital • Assessed by respirology • Diagnosed with pulmonary emboli • Diagnosed with COPD

8. Current Problems & Medications

9. DRPs • GB is at risk of experiencing subsequent VTE’s or death secondary to non-adherence to his warfarin therapy and would benefit from reassessment of therapy. • GB is at risk of C. difficile treatment failure secondary to receiving a short duration of vancomycin therapy and would benefit from a 10 day duration. • GB is at risk of experiencing adverse events secondary to receiving COPD therapy without a clear diagnosis and unclear severity and would benefit from reassessment of his COPD therapy. • GB is at risk of developing pneumonia secondary to not receiving his pneumococcal vaccine and would benefit from a one-time administration of the vaccine.

10. DRP Focus • GB is at risk of experiencing adverse events secondary to receiving COPD therapy without a clear diagnosis and unclear severity and would benefit from reassessment of his COPD therapy.

11. COPD • Gradual & progressive loss of lung function due to chronic inflammatory changes • Chronic airflow limitation • alveoli lose elasticity • alveolar destruction • ↑ mucus production • Airway closure on expiration, leading to air trapping & hyperinflation nhlbi.nih.gov/health/health-topics/topics/copd/

12. COPD • Risk Factors • Cigarette smoking • Air pollution • Exposure to occupational dusts & chemicals • Clinical Presentation • Chronic cough • Sputum production • Dyspnea • ↑RR • Breathing with pursued lips • Hyperinflation of the lungs Can Respir J 2008;15(Suppl A):1A-8A

13. COPD • Our patient • COPD stage = mild • Hyperinflation present • Ø PFTs • Ø SOB • Ø exacerbations • Ø chronic cough • Ø sputum production • PTA Ø puffers

14. Goals of Therapy • Reduce mortality • Prevent or reduce hospitalizations • Reduce frequency & severity of exacerbations • Prevent disease progression • Improve QOL by reducing impairment & disability • Reduce adverse events

15. Therapeutic Approach Can Respir J 2008;15(Suppl A):1A-8A

16. Clinical Question • In a patient with at most mild COPD will an inhaled corticosteroid with an anticholinergic compared to a prn short-acting beta agonist reduce mortality and exacerbations, and improve quality of life and symptoms without increasing the risk of adverse events?

17. Literature Search

18. TRISTAN Lancet 2003; 361:449-56.

19. TRISTAN * SS vs. placebo + SS vs. combination Lancet 2003; 361:449-56.

20. TRISTAN • Limitations • Methodological • How many pts taking anticholinergics? • No adherence verification • Clinical • Primary outcome (FEV1) was a surrogate marker • Improvement in SGRQ not clinically significant • High drop-out rates • Pt has no subjective/objective data for having moderate-severe COPD • Pt would not fit criteria to be enrolled in study Lancet 2003; 361:449-56.

21. TORCH N Engl J Med 2007; 356:775-89.

22. TORCH * SS vs. placebo + SS vs. combination N Engl J Med 2007; 356:775-89.

23. TORCH • Limitations • Methodology • Sponsor employee performed statistical analysis • Underpowered for mortality outcome • Clinical • High drop out rates • Exacerbations: benefit from fluticasone or combo, must have 5 or 4 exacerbations/yr, respectively – not clinically significant • Improvement in SGRQ not clinically significant • Pt has no subjective/objective data for having moderate-severe COPD • Pt would not fit criteria to be enrolled in study N Engl J Med 2007; 356:775-89.

24. Summary of Evidence

25. Alternatives for Symptom Management • Short-acting beta agonist • Salbutamol • Anticholinergics • Ipratropium • Tiotropium • Long-acting beta-agonist • Salmeterol • Formeterol • Inhaled corticosteroids

26. Application to GB

27. Therapeutic Plan • Discontinue fluticasone 500 mcg INH BID • Discontinue ipratropium 40 mcg INH QID • Discontinue salbutamol 200 mcg INH Q1H PRN • Initiate salbutamol 200 mcg INH Q4H PRN • Recommended one-time pneumococcal vaccine when stabilized

28. Monitoring Plan

29. Follow Up • All COPD inhaler recommendations were accepted by MTU team • Vancomycin increased to 10 days duration • Applied for SA for rivaroxaban for treatment of PE • Counseled patient on warfarin • Counseled patient on proper inhaler use • Recommended PFTs once stabilized