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9/5/2014
How to Manage
Advanced COPD:
What Every Home Health
Clinician Should Know
Amanda Weiland, PharmD
Clinical Pharmacist
HospiScript, a Catamaran Company
1
Learning Objectives
¾ Review the medications used to manage advanced chronic
obstructive pulmonary disease (COPD)
¾ Demonstrate patient assessment skills and decision-making
in pulmonary medication selection
¾ Identify communication strategies for improving agreement
and compliance with the plan of care for patients, family
members and clinicians
members,
2
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9/5/2014
Disclosure
¾ I have no relevant financial relationships with manufacturers
of any commercial products and/or providers of commercial
services discussed in this presentation
¾ This discussion will include the use of medications for offlabel indications
3
Air Movement in COPD
¾ Lungs are chronically over-inflated
• Chest wall and diaphragm move less
• Less negative pressure is generated in inspiration
• Patients use accessory muscles or arms to lift and lengthen thoracic
cavity
¾ Elastic recoil is reduced
• Positive pressure in expiration is reduced
• Expiration no longer passive but requires effort
¾ Airways are narrowed by inflammation
¾ Airways may collapse
• Expiration is slower
• Expiration takes more effort
4
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Categorization of Patients
Patient Classification
GOLD Spirometric Level
Summary of Characteristics
Patient Group A: Low
risk, Less symptoms
GOLD 1: Mild
0-1 exacerbations/year and no
hospitalization for exacerbation;
and CAT score < 10 or mMRC
grade 0-1
Patient Group B: Low
risk, More symptoms
GOLD 2: Moderate
0-1 exacerbations/year and no
hospitalization for exacerbation;
and CAT score > 10 or mMRC
grade > 2
Patient Group C: High
risk Less symptoms
risk,
GOLD 3: Severe
> 2 exacerbations/year or > 1
with hospitalization for
exacerbation; and CAT score <
10 or mMRC grade 0-1
Patient Group D: High
risk, More symptoms
GOLD 3 or 4 (Severe or Very Severe)
> 2 exacerbations/year or > 1
with hospitalization for
exacerbation; and CAT score <
10 or mMRC grade > 2
CAT = COPD Assessment Test
mmRC = Modified Briitsh Medical Research Council
5
Treatment of COPD
¾ Goals:
● Reduce symptoms
● Increase q
qualityy of life
● Prevent complications
¾ None of the existing medications for COPD have been shown
to modify the long-term decline in lung function
¾ Treatment should be patient specific
¾ Influenza and pneumococcal vaccination should be offered
to every COPD patient
6
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9/5/2014
Patient Case: 65 yo, ES COPD
Medications:
¾ Patient is a 65 yo
male with a PPS of
40% and end stage
COPD, O2 dependent
and a past medical
history of diabetes,
hypertension,
tobacco use, and
benign prostatic
hyperplasia (BPH).
Uncontrolled
symptoms include
dyspnea at rest and
pain.
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
Aspirin 81mg: Take 1 tab po daily
Senna-S: Take 1 tab po BID
Atenolol (Tenormin®) 25mg: Take 1 tab po daily
Montelukast (Singulair®) 10mg: Take 1 tab po daily
Roflumilast (Daliresp®) 500mcg: Take 1 tab po bid
Alprazolam (Xanax®) 0.5mg q4h prn anxiety/dyspnea
Tiotropium (Spiriva®) Inhaler: Inhale 1 puff daily
Insulin detemir (Levemir®) Flexpen: Inject 20units SQ daily
Tamsulosin ((Flomax®) 0.4mg:
g Take 1 cap
pp
po dailyy
Insulin aspart (Novolog®) Flexpen: Inject 3units SQ twice daily
Prednisone 10mg: Take 1 tab po daily
Ipratropium/albuterol (DuoNeb®) Solution: 1 vial 4-6 times per day
Budesonide/formoterol (Symbicort®): Inhale 2 puffs BID
Albuterol (Proair®) HFA Inhaler: Inhale 2 puffs Q6H prn
7
Medications for Pulmonary Disease
¾ Bronchodilators
● Beta2 agonists
● Anticholinergics
¾ Corticosteroids
¾ Other Medications
● Leukotriene Receptor Antagonists
● Guaifenesin (Mucinex®)
● Roflumilast (Daliresp®)
● Theophylline
8
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Inhalers & Nebulized Meds
¾ Mainstays of COPD therapy
¾ Therapy is layered based on patient risk factors and severity
of symptoms
● Low risk, few symptoms = bronchodilator PRN
● High risk, severe symptoms = rational polypharmacy
¾ Therapy through the inhaled route requires attention to
effectiveness
ff ti
off d
drugg d
delivery
li
and
d training
t i i g off inhaler
i h l
technique
9
Beta2 Agonists: Pharmacology
¾ Relax bronchial smooth muscles (bronchodilation) by
stimulating beta2 receptors
● Duration of action varies by agent
− Range: 4 – 24 hours
● Effect on heart rate varies by medication
− All beta2 agonists carry risk, especially with overuse and duplication of
therapy
− Short-acting > long-acting
− Albuterol > levalbuterol
10
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Beta2 Agonists: Dosing & Use
¾ Used in combination with inhaled corticosteroids and
anticholinergic inhalers, +/- oral meds
¾ Longer-acting agents (LABA)
● Dose Q12 or Q24 hours
● Scheduled use for maintenance & prevention
¾ Shorter-acting agents (SABA)
● Dose Q4 or Q6 hours
● Commonly used PRN for breakthrough symptoms
● Rescue inhalers
11
Beta2 Agonists: Adverse Effects
¾ Chest pain, palpitations, anxiety, dizziness, tremor,
pharyngitis
¾ Risk of adverse effects in increased, without additional
clinical benefit to patient when:
● More than one beta2 agonist is ordered for routine use
● Beta2 agonist inhaler is overused by patient
12
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Beta2 Agonists: Avoiding Duplications
¾ Medication profile review at each visit
● Any new additions
● Anyy inhalers missed or forgotten
g
about from last visit
● Are inhalers being refilled “too soon”
¾ Recognize duplications
● Know the medications in each class (especially combination inhalers!)
● Scheduled short-acting agents are equivalent to a long-acting agent
− Ex:
E albuterol
lb
l Q6H ATC ≈ arformoterol
f
l (B
(Brovana®)
®) Q12H ATC
13
Beta2 Agonists: SABA Options
Generic
(Brand)
Dosing
Interval
Dosage Forms FDA Approved Generic
Indication
Available?
Average
Cost/Month
(AWP)
Short Acting Beta Agonist (SABA)
Albuterol
(AccuNeb®,
Ventolin®,
ProAir®)
Q4-6H
Nebulizer (Neb),
aerosol inhalation
tablets
Asthma, COPD
Yes
$47 HFA /
$75 Neb /
$1500 tabs
Levalbuterol
(Xopenex®)
Q6-8H
Nebulizer, aerosol
inhalation
Asthma
Yes (Neb)
$105 HFA /
$525 Neb
Metaproterenoll
M
(Alupent®)
Q4 6H
Q4-6H
T bl
Tablets,
syrup
A h
Asthma,
COPD
Y
Yes
$140 tablets
bl
Terbutaline
(Brethine®)
Q6H
Tablets
Asthma
Yes
$63 tablets
HFA = hydrofluoroalkane
MDI = metered dose inhaler
14
Lexi‐Comp Online [Internet database]. Lexi‐Drugs Online, Hudson, Ohio: Lexi‐Comp, Inc. Accessed Feb 25,2014
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Beta2 Agonists: LABA Options
Generic
(Brand)
Dosing
Interval
Dosage
Forms
FDA Approved Generic
Indication
Available?
Average
Cost/Month
(AWP)
Long Acting Beta Agonist (LABA)
Arformoterol
(Brovana®)
BID
Nebulizer
COPD
No
$620 Neb
Formoterol
(Foradil
Aerolizer®,
Perforomist®)
BID
Nebulizer, Dry
Powder Inhaler
Asthma / COPD
No
$610 Neb /
$300 DPI
Indacaterol*
(Arcapta®)
QD
Dry Powder
Inhaler
COPD
No
$220 DPI
(capsules)
Salmeterol
(Serevent®)
BID
Dry Powder
Inhaler
Asthma / COPD
No
$288 MDI
DPI = dry powder inhaler
*newer medication, dosage form
15
Lexi‐Comp Online [Internet database]. Lexi‐Drugs Online, Hudson, Ohio: Lexi‐Comp, Inc. Accessed February 26, 2014
Anticholinergics: Pharmacology
¾ Provide bronchodilation by inhibiting acetylcholine at type 3
muscarinic (M3) receptors in bronchial smooth muscle
● Duration of action varies by medication
− Range: 6 – 24 hours
● Inhaled anticholinergics have same mechanism of action as oral
anticholinergics, with less systemic effect
− Anticholinergic side effect risk increases with overuse and duplication of
therapy
16
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Anticholinergics: Dosing & Use
¾ Used in combination with inhaled corticosteroids and LABA or
SABA inhalers, +/- oral meds
¾ Longer acting agents
● Q12 or 24 hours
● Scheduled use only, for maintenance and prevention
¾ Shorter acting agent
● Q4 or 6 hours
● Scheduled or PRN use
− Recommend scheduled in severe disease
17
Anticholinergics: Adverse Effects
¾ Bronchitis, sinusitis, headache, dry mouth, dizziness, urinary
retention
¾ SLUDGE: Salivation, Lacrimation, Urination, Defecation, GI,
Emesis
¾ Cautious use if glaucoma, BPH, renal impairment
¾ Risk of adverse effects increased when
● Multiple anticholinergic medications ordered
− Both oral or inhaled contribute to adverse effects
− Common examples listed in chart
● Anticholinergic inhalers overused
18
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Anticholinergics: Avoiding Duplications
¾ Medication profile review at each visit
● Any new additions – oral, inhalers, nebs
● Anyy inhalers missed or forgotten
g
about from last visit
● Are inhalers being refilled “too soon”
¾ Recognize duplications
● Know the medications in each class (especially combination inhalers!)
● Scheduled short-acting agents are equivalent to a long-acting agent
− Ex:
E ipratropium
i
i
(A
(Atrovent®)
®) Q6H ATC ≈ tiotropium
i
i
(S
(Spiriva®)
i i ®) QDay
QD
19
take note
Short acting bronchodilators used routinely
=
Long acting bronchodilator
20
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9/5/2014
Anticholinergics: Options
Generic
(Brand)
Dosing
Interval
Dosage
Forms
FDA Approved
Indication
Generic
Available?
Average
Cost/Month
(AWP)
Short Acting
Ipratropium
(Atrovent®)
Q4-6H
Nebulizer,
Aerosol
inhaler
COPD
Yes
$280 HFA
$140 Neb
Long Acting
Aclidinium*
(Tudorza
Pressair®)
BID
Dry Powder
Inhaler
COPD
No
$261 DPI
Tiotropium
(Spiriva®)
QD
Powder
Capsule
Inhaler
COPD
No
$305 DPI
*newer medication, dosage form
21
Lexi‐Comp Online [Internet database]. Lexi‐Drugs Online, Hudson, Ohio: Lexi‐Comp, Inc. Accessed Feb 26,2014
Oral Anticholinergic Duplications
Class
Examples
Antihistamines
Diphenhydramine (Benadryl®), Meclizine (Antivert®),
Hydroxyzine (Atarax®)
Meds for Urinary
Incontinence
Tolterodine (Detrol®), Oxybutynin (Ditropan®)
Tricyclic Antidepressants
Amitriptyline (Elavil®), Desipramine (Norpramin®),
Nortriptyline (Pamelor®)
Muscle Relaxants
Cyclobenzaprine (Flexeril®)
Antispasmodics
Dicyclomine (Bentyl®), Hyoscyamine (Levsin®)
A ti
Antiemetics
ti
Promethazine
P
th i (Ph
(Phenergan®),
g ®) Prochlorperazine
P hl
i
(Compazine®)
Antipsychotics
Chlorpromazine (Thorazine®)
Anti-Parkinson agents
Benztropine (Cogentin®), Trihexyphenidyl (Artane®)
22
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Inhaled Corticosteroids: Pharmacology
¾ Control bronchial inflammation by suppressing leukocytes
and decreasing capillary permeability
● Anti-inflammatory, immuosuppressive, anti-proliferative
● Oral and inhaled corticosteroids (CS) have similar effects
● Inhaled CS primarily local action in lungs
● Inhaled CS limit the systemic exposure and reduce long term
corticosteroid adverse effect risk
¾ Duration of action is similar for all
● Range: 12-24 hours
23
Inhaled Corticosteroids: Dosing & Use
¾ Used in combination with inhaled anticholinergics and LABA
or SABA inhalers, +/- oral meds
● Dose Q12H for maintenance and prevention
● Scheduled use only!
● No PRN use of inhaled corticosteroids!
24
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Inhaled Corticosteroids: Adverse Effects
¾ Oropharyngeal thrush, throat irritation, respiratory infection,
rhinitis, headache
¾ Risk of adverse effects is increased, without additional
clinical benefit to patient when:
● More than one inhaled CS is ordered for routine use
● Inhaled CS and oral CS are ordered routinely
● Overuse or improper use of inhaled CS
25
Oral Corticosteroids: Adverse Effects
¾ Edema, hyperglycemia, hypertension, peptic ulcer, bruising,
impaired wound healing
●
For higher functioning (non-hospice) patients, inhaled CS is preferred
for maintenance with added oral CS bursts for exacerbations as
needed
●
For poorer functioning (hospice/end stage) patients, added benefit
from oral CS for appetite, mood, pain plus difficulty in proper use of
inhaled CS
26
13
9/5/2014
Inhaled Corticosteroids: Avoiding Duplications
¾ Medication profile review at each visit
● Any new additions – oral, inhalers, nebs
● Anyy inhalers missed or forgotten
g
about from last visit
● Are inhalers being refilled “too soon” or “too late”
¾ Recognize duplications
● Know the medications in each class (especially combination inhalers!)
● Short term “steroid bursts” to manage exacerbations may be added to
a scheduled inhaled CS
27
Inhaled Corticosteroids (ICS)
Generic
(Brnad)
Dosing
Interval
Dosage Forms
FDA Approved
Indication
Generic
Available?
Average
Cost/Month
(AWP)
Beclomethasone
B
l
th
(QVAR®)
BID
A
Aerosol
l Inhaler
I h l
A th
Asthma
N
No
$209 MDI
Budesonide
(Pulmicort®)
BID
Nebulizer,
Powder Inhaler
Asthma
Yes (neb)
$500 Neb /
$205 DPI
Ciclesonide
(Alvesco®)
BID
Aerosol Inhaler
Asthma
No
$209 MDI
Flunisolide*
(Aerospan®)
BID
Aerosol Inhaler
Asthma
No
$380 MDI
Fluticasone
(Flovent®)
BID
Aerosol Inhaler,
Powder Inhaler
Asthma
Yes (neb)
$340 HFA /
$150 DPI
Mometasone
(Asmanex®)
BID
Aerosol Inhaler
Asthma
No
$180 MDI
*new medication, dosage form
28
Lexi‐Comp Online [Internet database]. Lexi‐Drugs Online, Hudson, Ohio: Lexi‐Comp, Inc. Accessed Feb 26, 2014
14
9/5/2014
Oral Corticosteroids
Generic
(Brand)
Dosing
Interval
Dosage
Forms
FDA Approved
Indication
Generic
Available?
Average
Cost/Month
(AWP)
Dexamethasone
(Decadron)
QD to Q6H
Tablet,
Solution,
Injectable
Anti-inflammatory,
Antiemetic, multiple
others
Yes
$10 - $20 Tabs
Methylprednisolone
(Medrol,
Solu-Medrol, DepoMedrol)
QD to Q6H
Tablet,
Injectable
Anti-inflammatory,
Acute Asthma,
multiple others
Yes
$40 - $80 Tabs
P d i
Prednisone
(Deltasone)
QD to
t Q6H
T bl t
Tablet,
Solution,
A t Asthma,
Acute
A th
Pneumonia, RA,
multiple others
Y
Yes
$5 - $20 Tabs
T b
RA= rheumatoid arthritis
29
Lexi‐Comp Online [Internet database]. Lexi‐Drugs Online, Hudson, Ohio: Lexi‐Comp, Inc. Accessed Feb 26, 2014
Combination Inhaled Products
Generic
(Brand)
Dosing
Interval
Dosage Forms FDA Approved
Indication
Generic
Availabl
e?
Average
Cost/Month
(AWP)
Budesonide/
B
desonide/
Formoterol
(Symbicort®)
BID
Aerosol Inhaler
Asthma/COPD
No
$280MDI
Fluticasone/ Salmeterol
(Advair HFA®, Advair
Diskus®)
BID
Aerosol, Powder
Inhaler
Asthma/COPD
No
$375HFA
$400DPI
Mometasone/
Formoterol*
(Dulera®)
BID
Aerosol Inhaler
Asthma
No
$235 MDI
Vilanterol/ Fluticasone
furoate*
(Breo Ellipta®)
QD
Powder inhaler
COPD
No
$320 DPI
Ipratropium/ Albuterol*
(Combivent Respimat®,
Duoneb®)
Q4-6H
Nebulizer,
Aerosol Inhaler
Asthma/COPD
Yes
(nebs
only)
$288 MDI
$120Neb
*newer medication, dosage form
30
Lexi‐Comp Online [Internet database]. Lexi‐Drugs Online, Hudson, Ohio: Lexi‐Comp, Inc. Accessed Feb 26, 2104
15
9/5/2014
Leukotriene Receptor Antagonists
¾ Control inflammation, inhibit bronchoconstriction, decrease
airway edema
● Montelukast (Singulair®) average cost $170/month
● Zafirlukast (Accolate®) average cost $117/month
¾ FDA-approved for asthma, seasonal allergies only
● No evidence for use in COPD
● Use not supported in 2013 GOLD guidelines
¾ Adverse effects: headache, nausea, diarrhea, abdominal
pain, insomnia, flu-like symptoms
31
Roflumilast (Daliresp®)
¾ Bronchodilation due to inhibition of phosphodiesterase type
4; exact mechanism is unknown, but provides antiinflammatory activity
¾ FDA approved indication: COPD
¾ Average cost (AWP): $240/month (tablets)
¾ Adverse effects: diarrhea, weight loss, nausea, decreased
appetite, headache, dizziness, depression and insomnia
● Dose adjustment required in liver disease
32
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9/5/2014
Guaifenesin (Mucinex®)
¾ Irritates the gastric mucosa, stimulates respiratory tract
secretions, decreases mucus viscosity
¾ Goal is to loosen phlegm for easier expectoration and
elimination
● Encourage fluids, give with 8 oz of water for benefit
● Anticholinergic use can reduce effectiveness
● Use cough suppressants at night to reduce sleep interruption or for painful
productive cough
¾ Average
A
g costt (AWP)
(AWP): $25/
$25/month
th (t
(tablets)
bl t )
¾ Adverse effects: dizziness, drowsiness, headache, nausea
¾ Max dose 2400mg/day
● Higher doses no benefit and increased adverse effects
33
Theophylline (Theo-Dur®)
¾ Causes bronchodilation, diuresis, CNS and cardiac
stimulation, and gastric acid secretion; exact mechanism is
unknown
¾
FDA approved for asthma/COPD
¾
Average cost (AWP): $40/month (tablets), $111/month (elixir)
¾
Adverse Effects: tachycardia, atrial flutter, headache,
insomnia restlessness
insomnia,
restlessness, seizures,
seizures tremor
●
Narrow therapeutic index:
−
Signs of toxicity from chronic overexposures: cardiac dysrhythmias,
tachycardia, persistent and repetitive vomiting
−
Risk factors for toxicity: age > 60 yrs, drug-drug interactions
34
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9/5/2014
Future of COPD Pharma
¾ Inhalers containing CFC propellants have phased out
● CFC (chlorofluorocarbon) damages ozone layer
● Dec 2013 Combivent® MDI already replaced with Combivent Respimat®
● Fall 2013 Aerospan® to replace Aerobid® phased out in 2011
¾ New inhaled medications
● ICS: Fluticasone furoate
● LABA: Vilanterol, Olodaterol
● Anticholinergics: Umeclidinium, Glycopyrronium
● Combo
C b LABA/LA anticholinergic:
ti h li gi umeclidinium/vilanterol
lidi i / il t l (Anoro
(A
Elli t )
Ellipta)
¾ New delivery devices
● Respimat® (Boehringer Ingelheim), Ellipta® (GSK-Theravance), Breezehaler®
(Norvartis)
35
Choosing a Medication
¾ Choice within each class of medications depends on:
● Availability
● Cost
● Patient response
● Patient’s skills and ability to utilize the medication
¾ Choice between which medication class to start depends on the
patient’s current pulmonary status
¾ Patient Group A-D
36
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9/5/2014
Treatment Guidelines
Patient Group
Recommended First Choice
Patient Group A: Low risk, Less
symptoms
SABA prn
or
Sh
Short-acting
i anticholinergic
i h li
i prn
Patient Group B: Low risk, More
symptoms
Long-acting anticholinergic
or
LABA
Patient Group C: High risk, Less
symptoms
Inhaled CS + LABA
or
Long-acting anticholinergic
Patient Group D: High risk, More
symptoms
Inhaled CS + LABA and/or long-acting
anticholinergic
37
take note
Rational polypharmacy in COPD is using multiple
different medications that have similar goal of
treating dyspnea
38
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9/5/2014
What Can You Do for Patients with COPD?
Ensure symptom relief with medications
+
Determine if decline or disease progression despite
medication adherence and appropriate inhaler use
+
Keep the discussions patient-centered
Continuously monitor for:
1. Appropriate use of inhalers
2. Frequency of use of inhalers
3. Duplications in therapy
4. Adverse effects from medications
39
Managing Exacerbations of COPD
¾ Reduce Trigger Risk (if possible)
● Respiratory Infections: (Viral or Bacterial)
● Allergies (indoor & outdoor)
● Anxiety
● Co-morbid heart failure: pulmonary edema
¾ Be prepared for home management of exacerbations
● Oral steroid bursts
● Antibiotics if bacterial infection suspected
● Supplemental oxygen
● Palliative symptom management
40
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9/5/2014
Managing Exacerbations of COPD
¾ Oral steroid bursts
● Prednisone 40mg PO Daily x 5 days; then return to prior maintenance
CS regimen (lower dose oral or ICS)
¾ Increase dose or frequency of short-acting bronchodilators
● Change to nebulizer delivery (if not already using)
¾ Consider antibiotics when clinical bacterial infection signs
present
● Increased sputum purulence, increased sputum volume, increased
dyspnea
41
Managing Exacerbations of COPD
¾ Antibiotics
● Choice of antibiotic depends on local resistance patterns
● Use “Respiratory
p
y antibiotics”, for 5- 10 days
y
● Oral antibiotics preferred
● Avoid using same antibiotic class within 3 months
Antibiotic
Class
Amoxicillin-clavulanic acid (Augmentin®)
Penicillin
Cefpodoxime
3rd generation cephalosporin
Azithromycin (Zithromax®) or clarithromycin
(Biaxin®)
Macrolide
Doxycycline
Tetracycline
Levofloxacin (Levaquin®) or Moxifloxacin
(Avelox®)
Fluoroquinolone
42
21
9/5/2014
take note
Antibiotics should be used only when symptoms
of bacterial infection are present
AND
When treatment is in line with the patient’s
goals
43
Palliative Dyspnea Management
¾ Low doses of short-acting opioids are the mainstays of
palliative dyspnea management
¾ Extreme anxiety can accompany the sensation of dyspnea,
low dose benzodiazepines may also be useful
¾ Starting doses recommended for opioid-naïve patients:
● Morphine 2.5mg PO/SL every 2 hours as needed for dyspnea
● Lorazepam 0.25mg PO/SL every 4 hours as needed for dyspneaassociated anxiety
44
22
9/5/2014
Patient Case: 65 yo, ES COPD
Medications:
¾ Patient is a 65 yo
male with a PPS of
40% and end stage
COPD, O2 dependent
and a past medical
history of diabetes,
hypertension,
tobacco use, and
benign prostatic
hyperplasia (BPH).
Uncontrolled
symptoms include
dyspnea at rest and
pain.
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
Aspirin 81mg: Take 1 tab po daily
Senna-S: Take 1 tab po BID
Atenolol (Tenormin®) 25mg: Take 1 tab po daily
Montelukast (Singulair®) 10mg: Take 1 tab po daily
Roflumilast (Daliresp®) 500mcg: Take 1 tab po bid
Alprazolam (Xanax®) 0.5mg q4h prn anxiety/dyspnea
Tiotropium (Spiriva®) Inhaler: Inhale 1 puff daily
Insulin detemir (Levemir®) Flexpen: Inject 20units SQ daily
Tamsulosin ((Flomax®) 0.4mg:
g Take 1 cap
pp
po dailyy
Insulin aspart (Novolog®) Flexpen: Inject 3units SQ twice daily
Prednisone 10mg: Take 1 tab po daily
Ipratropium/albuterol (DuoNeb®) Solution: 1 vial 4-6 times per day
Budesonide/formoterol (Symbicort®): Inhale 2 puffs BID
Albuterol (Proair®) HFA Inhaler: Inhale 2 puffs Q6H prn
45
Where Do We Start?
¾ After any acute symptoms are controlled:
● Step 1: Assess for adverse effects
− Review medication profile
− Adverse effects from polypharmacy, incorrect use
● Step 2: Eliminate duplications
− Review medication profile
− Reduces polypharmacy
− Reduces adverse effect exposure risk
46
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9/5/2014
Patient Case: 65 yo, ES COPD
¾ Without adjusting inhalers, how would you manage the
patient's symptoms?
● Add morphine 20mg/mL 2.5-5mg PO/SL/PR q2h prn pain/dyspnea
● Schedule alprazolam 0.5mg TID and continue q4h prn
● Steriod burst (i.e. Prednisone 40mg PO daily x 5 days) then return to
lower daily dose
● Non-pharmacologic management
47
Patient Case: 65 yo, ES COPD
Medications:
¾ Patient is a 65 yo
male with a PPS of
40% and end stage
COPD, O2 dependent
and a past medical
history of diabetes,
hypertension,
tobacco use, and
benign prostatic
hyperplasia (BPH).
Uncontrolled
symptoms include
dyspnea at rest and
pain.
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
¾
Aspirin 81mg: Take 1 tab po daily
Senna-S: Take 1 tab po BID
Atenolol (Tenormin®) 25mg: Take 1 tab po daily
Montelukast (Singulair®) 10mg: Take 1 tab po daily
Roflumilast (Daliresp®) 500mcg: Take 1 tab po bid
Alprazolam (Xanax®) 0.5mg q4h prn anxiety/dyspnea
Tiotropium (Spiriva®) Inhaler: Inhale 1 puff daily
Insulin detemir (Levemir®) Flexpen: Inject 20units SQ daily
Tamsulosin ((Flomax®) 0.4mg:
g Take 1 cap
pp
po dailyy
Insulin aspart (Novolog®) Flexpen: Inject 3units SQ twice daily
Prednisone 10mg: Take 1 tab po daily
Ipratropium/albuterol (DuoNeb®) Solution: 1 vial 4-6 times per day
Budesonide/formoterol (Symbicort®): Inhale 2 puffs BID
Albuterol (Proair®) HFA Inhaler: Inhale 2 puffs Q6H prn
•Duplication of therapy
48
24
9/5/2014
Plan to Address Duplications of Therapy
¾ IF the patient is on Symbicort®, Spiriva®, Daliresp®, prednisone and
Duoneb® nebulized scheduled QID...
¾ THEN there are duplications of:
● Corticosteroids: budesonide (Symbicort®) and prednisone
● Anti-inflammatories: Daliresp®, budesonide (Symbicort®), prednisone
● Anticholinergics: tiotropium (Spiriva®), ipratropium (Duoneb®)
● Beta-agonists: formoterol (Symbicort®), albuterol (Duoneb®)
¾ SO to eliminate duplications
p
and utilize the most cost effective therapy:
py
● Discontinue Symbicort®, Spiriva®, and Daliresp®
● Continue prednisone (consider burst or increase maintenance dose)
● Continue Duoneb® nebulized QID
49
Assessing Inhaler Appropriateness
¾ MDIs and DPIs require good breathing coordination and
inspiratory capacity to use properly
¾ Evaluate patient ability to use inhalers for both ability to
inhale deeply, cognitive and physical ability to coordinate
inhalation with inhaler activation
¾ Evaluation and discussion about appropriateness of these
medications
di ti
MUST occur on an ongoing
g i gb
basis
i
50
25
9/5/2014
Assessing Inhaler Appropriateness
¾ To determine if the inhalers are used correctly, follow these
three steps:
1.
2.
Ask the patient to demonstrate how they use the inhaler
Demonstrate appropriate use of the inhaler by walking the patient
through the steps
•
3.
Stress the importance of holding your breath for ten seconds after
inhaling the medication
Have the patient use the inhaler again using appropriate
technique
¾ If the patient cannot complete the above steps, the
medication is not reaching the site of action in the lungs
and therefore is not beneficial
51
Inhaler Technique
Dry powder inhaler (DPI)
For efficient use, patient must be able to:
1 Follow instructions to prepare specific DPI device for use (diskus
1.
(diskus, flexhaler,
flexhaler
twisthaler)
2. Turn head away from device to exhale completely
3. Close mouth around mouthpiece
4. Inhale forcefully, steadily, and deeply to propel medicated powder into
lungs
5. Hold breath for 10 seconds
6. Remove DPI from mouth and exhale slowly
7. Repeat steps 1-6 if more than 1 inhalation is prescribed
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9/5/2014
Inhaler Technique
Metered dose inhaler (MDI)
For efficient use, patient must be able to:
1. Follow
o o instructions
st uct o s to prepare
p epa e specific
spec c MDI device
de ce for
o use (traditional
(t ad t o a
MDI, Respimat®)
2. Shake inhaler and hold properly
3. Position for open airway inhalation
4. Exhale completely
5. Close mouth around device mouthpiece
6. Activate inhaler device timed to start of inspiration
7. Slowly and deeply inhale medication over 5-7 seconds
8. Hold breath for 10 seconds
9. Wait 1 minute and repeat steps 1-7 if more than 1 inhalation is
ordered
53
When to Assess Ability to Use Inhalers
Assess & document patient’s ability to use inhalers:
1.
2
2.
3.
4.
5.
6.
With any exacerbation of condition
With a decline in status
At every recertification
Prior to ordering inhaler refills
On admission to hospice
With every change in location (transfer to/from ECF, IPU,
hospital,
p , etc))
54
27
9/5/2014
Overuse of Inhalers
55
Non-Pharmacological Management
¾ Positioning
● Providing an over the bed table will help patients to position
themselves with their head up and support their elbows and arms to
allow lengthening and expansion of the chest cavity
¾ Environment
●
●
●
●
●
Fan directed at face
Provide visual signs of air movement (ribbons on fan)
Cool air
Minimize odors
Avoid closed in spaces
56
28
9/5/2014
Non-Pharmacological Management
¾ Smoking cessation
● Depends on patient’s goals of care
● Smokingg can exacerbate dyspnea,
y p
mucus and cough
g
● Smoking is life-threatening when patients are also using oxygen or fall
asleep while smoking
● Nicotine replacement products may be a useful alternative to reduce
symptoms and address safety concerns
57
Non-Pharmacological Management
¾ Support
● Psychosocial, emotional and spiritual support is extremely helpful in
reducing fear, anxiety, and depression
¾ Oxygen therapy
● Considered for any patient with hypoxemia (O2 Saturation < 90%)
and during periods of exacerbation
¾ Rehabilitation
● Considered for any patient go becomes dyspneic when walking at
their own pace on level ground
● It can improve symptoms and quailty of life as well as participation in
other activities
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29
9/5/2014
Communication
Strategies
The BUILD Model
59
Difficult Discussions
¾ Patients, families and physicians have grown accustomed to
the current medication regimen
¾ Discussing discontinuing therapy may result in a sense of
abandonment or loss of hope
¾ Ways to address these feelings:
● Communication and collaboration with the patient’s attending
physician
● Asking the patient what provides him/her comfort
60
30
9/5/2014
Planned Discussions
¾ At time of admission
¾ When it’s time to re-order a medication that is regarded as
life p
prolonging
g g or delaying
y g disease p
progression,
g
i.e. Rilutek,
Namenda, Aricept
¾ When filling the patient’s pillbox or ordering refills
¾ During an extended care facility’s care conference
¾ Prior to recertification
61
Planned Discussions
¾ Whenever there is a change in location or Level of Care due
to a change in patient condition:
● Transfer to inpatient unit (IPU)
● Transfer to an extended-care facility (ECF)
● Continuous Care Initiated
¾ Whenever there is a need to change medications due to
patient condition:
● Patient having difficulty swallowing
● Patient less responsive
62
31
9/5/2014
Windows of Opportunity
Seizing the moment:
¾ “He takes pills all day long. No wonder he doesn’t have an
appetite.”
¾ “It takes 20 minutes to get his pills in him.”
¾ “I’m having to use my inhaler more often-sometimes every 2
hours.”
¾ “I can’t even walk to the door anymore because I’m so short
of breath.”
¾ “Mom
“M
doesn’t
d
’t even say my name anymore.””
63
Windows of Opportunity
Creating the moment:
¾ “You take a lot of medications, I’m wondering if some may be
causingg side effects?”
¾ “With so many medications, I’m wondering if you ever
prioritize the ones that are most important and skip others.”
¾ “I’m wondering if it’s difficult for you to think about
discontinuing medications that your mother has taken for a
long time.”
64
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9/5/2014
Talking Points for Patients and Families
¾ Follow the BUILD Model
● B-Build a foundation of trust and respect
● U
U-Understand
Understand what the patient and caregiver know about the
medication and the disease process
● I-Inform the patient and caregiver of evidence based information
about the medication
● L-Listen the patient and caregiver as they share their goals and
expectations
● D-Develop a plan of care (POC) in collaboration with the patient and
family
65
B-Build
¾ Follow the BUILD Model
● B-Build a foundation of trust and respect
− GOAL: Affirm the ppatient and caregiver;
g
; listen more than yyou talk. Validate
their efforts and concerns
− Key Phrases:
• “You do a great job advocating for your mother.”
• “It sounds like this has been a very challenging time for you.”
66
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9/5/2014
U-Understand
¾ U-Understand what the patient and caregiver know about the
medication and the disease process
●
Key phrases:
−
“How is the medication helpful to you?“
−
“What has the doctor told you about how this medicine works?”
−
“How will you know it’s time to stop the medicine/change the medicine?”
67
I-Inform
¾ I-Inform the patient and caregiver of evidence-based
information about the medication
● Key Phrases:
− “There are other medications used to treat shortness of breath/anxiety
that may be more effective than these inhalers for you.”
− “As your disease progresses it may be useful to make some adjustments
to your medications. What worked before may not work now.”
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9/5/2014
L-Listen
¾ L-Listen to the patient and caregiver as they share their
goals and expectations
● If the patient indicates a struggle with making a change, it may be
helpful to share experiences
● Key phrases:
− “We can’t reverse or cure your disease but there are many things we can
do to provide comfort and quality of life. What does quality of life look like
to you? What’s important to you?”
− “It sounds like it’s hard for you to make a decision about stopping the
Advair® inhaler. Can I share what my experiences and observations have
been?”
− “We really just want your breathing to be more comfortable. I want you to
know this is a team effort and you’re in charge of the team. I appreciate
you allowing me to talk with you today.”
69
D-Develop
¾ D-Develop a plan of care in collaboration with the patient
and family
● Goals need to be patient-centered and measurable
● Focus on patient comfort and what enhances quality-of-life
● Ask the patient for feedback regarding the plan and make
adjustments if needed
● Key phrases:
− “We work in collaboration with your doctor, who still guides your care and
wants you to be comfortable.”
− “You are not alone. We will walk this path with you. I’d like to come back
on Tuesday and we can talk more about this.”
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9/5/2014
Talking Points for Clinicians
¾ Keep the conversation patient-centered
● More than just relaying a message about medication use or cost
● Stress your assessment of the patient
− Inhaler use (frequency, ability, adverse effects)
− Decline/disease progression
• i.e. Comparison from a month ago to today
¾ Inform clinician of duplications of therapy
¾ Suggest adjusting therapy to improve symptom relief
¾ Recommend specific therapeutic alternatives
¾ Send results of therapy adjustment to physician
71
Talking Points for Clinicians
¾ Examples:
● "The patient is using the inhalers more than prescribed and is still
not having relief of symptoms.“
● "The patient cannot use the inhalers correctly and the medication is
not reaching the lungs.“
● "I have noticed a significant decline in the past month, the patient is
more dyspneic at rest despite current therapy.”
● “The patient no longer leaves the home or facility but still uses a
handheld rescue inhaler.”
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9/5/2014
Q
Questions?
ti
?
Amanda Weiland, PharmD, RPh
Clinical Pharmacist
HospiScript, A Catamaran Company
[email protected]
73
References
¾
Barrons R, Pegram A, Borries A. Inhaler device selection: special considerations in elderly patient with chronic obstructive pulmonary disease. Am J Health Syst Pharm. 2011;68:1221‐1232.
¾
Collier K, Protus B, Kimbrel J. Medication appropriateness at end‐of‐life: a new tool for balancing medicine and communication for optimal outcomes: the BUILD model. Home Healthcare Nurse 2013;31(9): in press DOI:10.1097/NHH.0b013e3182a5bf7c
¾
Food & Drug Administration (FDA). Drug treatments for asthma and COPD that do not use chlorofluorocarbons (CFC). FDA Drug S f & A il bili S
Safety & Availability Statement. http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm082370.htm
h //
fd
/D
/D S f /I f
i b D Cl /
082370 h
¾
End Stage COPD Guidance Document. HospiScript Services, LLC. 2013.
¾
Galbraith S, Fagan P, Perkins P, Lynch A (2010) Does the use of a handheld fam improve chronic dyspnea? A randomized, controlled , crossover trial. J Pain Symptom Manage. 2010;39(5):831‐838. ¾
Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med. 2010;170(18):1648‐1654. doi:10.1001/archinternmed.2010.355
¾
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. GOLD, Inc. 2013. http://www.goldcopd.org/guidelines-global-strategy-for-diagnosismanagement.html. Accessed May 2013
¾
Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern
Med. 2006;166(6):605‐609. doi:10.1001/archinte.166.6.605.
¾
Kamal AH, Maguire JM, Wheeler JL, et al. Dyspnea review for the palliative care professional: treatment goals and therapeutic
options. J Palliat Med. 2012;15(1):106‐114.
¾
Lanken PN, Terry PB, Delisser HM (2008) An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med. 2008;177(8):912–27
¾
Sorenson, HM. Improving end of life care for patients with chronic obstructive pulmonary disease. Ther Adv Respir Dis
2013;7(6):320‐6
¾
Lexi‐Comp Online [Internet database]. Lexi‐Drugs Online, Hudson, Ohio: Lexi‐Comp, Inc. Accessed Feb 26,2014.
74
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9/5/2014
Stages of COPD
GOLD Spirometric Level
Post-Bronchodilator FEV1 Exacerbations Hospitalizations 3-year
(FEV1/FVC < 70%;)
(per year)
(per year)
Mortality
GOLD 1: Mild
predicted
FEV1 ≥ 80% p
?
?
?
GOLD 2: Moderate
50% ≤ FEV1 < 80%
predicted
0.7-0.9
0.11-0.2
11%
GOLD 3: Severe
30% ≤ FEV1 < 50%
predicted
1.1-1.3
0.25-0.3
15%
GOLD 4: Very Severe
FEV1 < 30% predicted or
FEV1 < 50% predicted
plus chronic respiratory
failure
1 2-2
1.2
2.0
0
0 4-0
0.4
0.54
54
24%
GOLD = Global Initiative for Chronic Obstructive Lung Disease
75
38