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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 1 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 2 9/5/2014 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 3 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 4 9/5/2014 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 5 9/5/2014 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 6 9/5/2014 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 7 9/5/2014 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 8 9/5/2014 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 9 9/5/2014 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 10 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 11 9/5/2014 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 12 9/5/2014 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 16 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 17 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 18 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 19 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 20 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 23 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 52 26 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 58 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 32 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 33 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.” 68 34 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.” 70 35 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.” 72 36 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 37 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