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2011-04-14 21:17:46
Therapeutics Exam7 COPD

Therapeutics Exam7 COPD Koski
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  1. Classify a pt into a COPD class using the GOLD guidelines
    • Stage I: (Mild) FEV1 >/= 80% predicted
    • Stage II: (Moderate) 50% </= FEV1< 80% predicted
    • Stage III: (Severe) 30% </= FEV1< 50% predicted
    • Stage IV: (Very Severe) FEV1 < 30% predicted (or < 50% predicted plus chronic respiratory failure)
  2. What PFT value confirms a COPD diagnosis?
    FEV1/FVC < 70%
  3. What s/s are seen in each stage of chronic COPD?
    • Stage I (Mild) - may or may not have sx of chronic cough and sputum production
    • Stage II (Moderate) - SOB on exertion; cough and sputum production sometimes present; stage where pts usually seek medical attention d/t sx or exacerbation of disease
    • Stage III (Severe) - Greater SOB, reduced exercise capacity, fatigue, repeated exacerbations that usually impact QOL
    • Stage IV (Very Severe) - QOL significantly impaired, exacerbations may be life-threatening
  4. What is the mainstay of COPD treatment?
    inhaled bronchodilators
  5. What therapy is indicated in ALL stages of COPD?
    • active reduction of risk factors
    • short-acting bronchodilator PRN
  6. What tx is indicated in Stage I COPD?
    Short-acting bronchodilator PRN
  7. What are the 3 classes of short-acting bronchodilators and what meds fall into each class?
    • 1. Short-acting beta agonists - albuterol (MDI or neb), piralbuterol (MDI), levalbuterol (MDI or neb)
    • 2. Anticholinergics - ipratropium (MDI or neb)
    • 3. Combos - albuterol/ipratropium (MDI or neb)
  8. What is the indicated tx in Stage II COPD?
    • short acting bronchodilator prn +
    • one or more long-acting bronchodilators (scheduled)
  9. What are the 3 classes of long acting bronchodilators and which meds are in each class?
    • 1. Long acting beta agonists - Salmeterol (DPI), Formoterol (DPI or neb), Arfomoterol (neb)
    • 2. Anticholinergics - Tiotropium (DPI)
    • 3. Methylxanthines - Theophylline (PO)
  10. What is the indicated tx for Stage III COPD?
    • short acting bronchodilator prn +
    • one or more long acting bronchodilator +
    • inhaled glucocorticoids if repeated exacerbations
  11. What inhaled corticosteroids are used in COPD? What med could be used instead?
    • Beclomethasone (MDI)
    • Ciclesonide (MDI)
    • Budesonide/Formoterol (MDI)
    • Mometasone/Formoterol (MDI)
    • Mometasone (DPI)
    • Fluticasone (MDI or DPI)
    • Fluticasone/Salmeterol (DPI or MDI)
    • Budesonide (DPI or Neb)

    • Roflumilast could be used in place of ICS
    • PDE 4 inhibitor
  12. Indicated tx for Stage IV COPD
    • short acting bronchodilator PRN
    • long acting bronchodilator
    • inhaled corticosteroid
    • long term oxygen therapy (> 15 h/day)
    • consider surgical treatments
  13. What O2 Sat constitutes respiratory failure?
    < 88%
  14. Treatment for COPD exacerbation
    • Short acting bronchodilators (short acting beta agonist +/- anticholinergic e.g. albuterol + ipratropium) (almost always use nebs)
    • Oxygen if O2 sat < 90%
    • Glucocorticoids (short course 7-10 d) (PO not inferior to IV) (No tapering needed if using for < 14 d)
    • Antibiotics (macrolide, anti-pneumococcal FQ - moxifloxacin or levofloxacin, or 2nd/3rd gen ceph - ceftriaxone cefuroxime)
    • May add theophylline if needed
    • Discharge meds: complete course of steroids, short acting bronchodilator PRN, other meds as indicated by COPD Stage, complet course of antibiotics
  15. Which long acting bronchodilator is 1st line?
    Spiriva (tiotropium)
  16. How do we choose one short acting bronchodilator over another for use in COPD?
    • no one is really better than another
    • choice based on cost, convenience, and patient preference
    • options: nebulizer or MDI
  17. MOA of beta agonists
    • Stimulate B2 receptors to relax airway smooth muscle
    • decrease airway hyperresponsiveness
    • increase ciliary beat frequency
    • inhibit histamine release from mast cells
    • (decrease the work of breathing)
    • with LABAs tolerance can develop to the efficacy and SEs
  18. SEs of beta agonists
    • tachycardia
    • tremor
    • (with long acting tolerance can develop to the SEs and to the efficacy)
  19. How often are SABAs and LABAs used?
    • SABAs are usually Q4-6 h prn
    • LABAs are usually bid
  20. Are long acting anticholinergics or LABAs preferred? Why?
    long acting anticholinergics because studies show better efficacy and no tolerance
  21. MOA of anticholinergics in COPD
    • inhibit binding of Ach to receptors in the bronchial smooth muscle resulting in bronchodilation
    • inhibit mucus production
  22. SEs of anticholinergics in COPD
    • dry mouth
    • nausea
    • metallic taste
  23. On what schedule should a pt use anticholinergics for COPD?
    • short acting are usually Q4-6 h prn
    • long acting may be QD (but a scheduled short acting would probably be QID)
  24. Efficacy of ICS in COPD
    • reduce frequency of exacerbations
    • improve health status
    • don't reduce mortality
  25. SEs of ICS in COPD
    • hoarseness
    • oral thrush
    • cough
    • possible decrease in bone mineral density and increased fracture risk
    • possible pneumonia risk
    • possible afib risk
  26. Usual schedule for ICS in COPD
    • QD to BID
    • with Advair (fluticasone/salmeterol) if dose increase is needed, cannot just increase the # of puffs, must increase the strength
  27. What is the goal theophylline level for COPD?
    5-15 mcg/ml = 5-15 mg/l
  28. What is the appropriate duration of a steroid burst for a COPD exacerbation?
    • maximum 7-10 days
    • no taper needed if < 14 days
  29. What is FEV1?
    • forced expiratory volume in one second
    • measurement of how much air is exhaled in the first second
    • determines stage of COPD
    • decreased in obstructive lung disorders
  30. What is FVC?
    • forced vital capacity
    • the total volume exhaled after max inhalation
    • may be decreased or normal in obstructive lung disorders
  31. What is FEV1/FVC?
    • diagnostic ratio that tells us if a pt has COPD if it is < 70%
    • decreased in obstructive lung disorders
  32. Compare COPD and asthma in terms of diagnosis and treatment
    • Both are: obstructive lung diseases, monitored by PFTs, can use combo corticosteroid/LABA, use SABA/Anticholinergic in exacerbations, both have SOB/cough
    • With asthma: 1st line tx is CS (CS decr mortality), SABA decr sx, PFTs respond to SABAs (FVC incr by 12%+), LABAs not monotx, wheeze, chest tightness are sx
    • With COPD: 1st line tx is long acting bronchodilator, CS do not decr mortality, SA anticholinergics or SABAs decr sx, PFTs non responsive to SABAs, LABA is good monotx, wheeze and chest tightness are not normal sx
  33. Theophylline SEs
    • n/v
    • tachycardia, arrhythmias
    • HA, insomnia, seizures
  34. What enzyme is theophylline a substrate of? What factors increase the metabolism of theophylline?
    • CYP 1A2 substrate
    • tobacco smoking
    • anticonvulsants
    • rifampin
    • alcohol
    • need higher theoph dose to get to therap level if these factors are present