copd template

7/23/2019 Copd Template

1/27

CRITER

IA

EVIDENCE

PO

A cough, difculty o breathing, sputum production

B STATEMENT/STUD !"#TAT#$N%

C STATEMENT/STUD !"#TAT#$N%

D STATEMENT/STUD !"#TAT#$N%

USE TS T'E $( TA)*E AND ($NT ST*ESE"U+E T&E ''T $( T&E T$'#"S ASS#NED T$ $U


2/27

CRITERIA EVIDENCE PO

1 +elie o breathlessness and e-ercise limitation !AmericanThoracic Society, .01%

3 This selecti3ity o muscarinic antagonists accounts or their

useulness as in3estigati3e tools in e-amining the role oparasympathetic path4ays in bronchomotor responses butlimits their useulness in pre3enting bronchospasm 4ithminimal drug tolerance !5at6ung, Masters, 7 Tre3or, .0.%8

2/4 Their duration o action is appro-imately 9 to : h, butcompared 4ith SA)As, they ha3e a slo4er onset o actionbut ha3e longer duration o action8!"a66ola et al8, 0;;:en as amonotherapy or e-acerbation and is al4ays used incombination 4ith SA)A because o its slo4er onset o



3/27


4/27


CRITE

RIA

EVIDENCE

PO

1 +e3ersible symptoms o? parado-ical acutebronchospasm, cough, throat irritation and drymouth in 0@ but is due to long term use8 !uy,.00%

2/3 #nhaled ipratropium sho4s little or no e3idence oad3erse hemodynamic or ocular eBects, ordetrimental eBects on sali3ation, micturition, orarterial blood gases due to its lo4 lipid solubility,thereore poor absorbability !e3en in #T% and does

not pass the blood=brain barrier !"a66ola et al8,0;;:%

2

4 )ronchodilatory eect may be intensiied by C=


5/27


6/27

CRITERIA

EVIDENCE

1 #nhaled mA"h+ antagonists ha3e been used as treatments orrespiratory diseases including "$'D but is not a recommendedas the rst line therapy or patients 4ith "$'D !$*D "at )%8

2 SAMA8Short=acting anticholinergics are not ta>en as amonotherapy or e-acerbation and is al4ays used in combination

4ith SA)A because o its slo4er onset o action !AmericanThoracic Society, .01%8

3 No contraindication to the patients clinical eatures8SAMA is contraindicated in patients with hypersensitivity to atropine-like substances.Special precautions in taking the drug must be given to patients with narrow-angleglaucoma & prostatic hypertrophy, cystic fbrosis.

4 *ong=term SAMA monotherapy on regular basis is notrecommended due to its short=lasting orm 4hich 4or>s in about0@ minutes and lasts or 9F: hours, and is usually ta>en G times aday 4hich diminishes patients compliance to the drug !Hoshar,et8al8 .: 8


7/27

CRITERIA PRICE PER WEEK

PO

Ipratropiumbromide

!Atro3ent inhalationsoln%

8@mg/.ml

1=G puBs per day

ST$"5? . puBs - 0s !'0,@;G8/bo-%

'E+ IEE5? .0=.: puBs/4ee>PRICE P2231/!ee"


8/27

CRITERI

A

EVIDENCE

1/2 Studies sho4ed a consistent impro3ement in lungunction and dyspnea scores in patients8 !Dahl

et8al8,.0< (riedman et8al8, .0< Iabdo et8al8, ..%8

3 *ong=term studies ha3e sho4n no e3idence odiminished responsi3eness !tachyphyla-is% 4ith regulartherapy8 !Seale, .9%8

4 The bronchodilating eBects o short=acting inhaledanticholinergics last longer compared to the short=actingbeta=agonists, 4ith some bronchodilator eBects lasting

up to : hours ater administration8 !$*D, .01%


9/27

CRITERIA

EVIDENCE

1/2 "linical trials ha3e also sho4n chronic use o *AMAs notonly reduces airJo4 limitation due to the disease but arealso associated 4ith impro3ements in Kuality o lie,symptom scores and reduced e-acerbations !Decrameret8al8, .0G< Ied6icha et8al8, .01< Hinc>en et8al8, ..%8

Studies obser3ed the ability o *AMAs to suppress mucussecretion thereby reducing the coloni6ation 4ith bacteriathat trigger e-acerbation e3ents !Decramer et8al8, .0G%

3 *ong=term studies ha3e sho4n no e3idence o diminishedresponsi3eness !tachyphyla-is% 4ith regular therapy8!Seale, .9%8

1 Tiotropium, once administered the onset obronchodilation occurs 4ithin 1 minutes, 4ith pea>acti3ity at 1 hours and sustained o3er more than .G


10/27

CRITERI

A

EVIDENCE

1/2 Studies o *A)A/*AMA combinations, to date, indicatethat combining diBerent classes o bronchodilator resultsin #i$%i&'a%t() $reater impro*eme%t# i% (u%$+u%'tio% and other mea%i%$+u( out'ome# #u', a#i%#pirator) 'apa'it)- d)#p%ea- #)mptom #'ore#-re#'ue medi'atio% u#e- a%d ,ea(t, #tatu# incomparison 4ith indi3idual drugs8 !Han der Molen et8al8,.01%

3 00 studies in total 4ith more than 0 patients across

@. countries, has documented a signicant impro3ementin lung unction and patient=reported outcomes includingbreathlessness and rescue medication use compared4ith current standard o care, reduced rates o "$'D


11/27

CRITERI

A

EVIDENCE

4 $nce administered the onset o bronchodilation occurs4ithin 1 minutes, 4ith pea> acti3ity at 1 hours andsustained o3er more than .G hours8 Ater regular oncedaily inhalation, it reaches a steady state ater . 4ee>sand is sustained a 4ee> more than a monotherapy o*A)A or *AMA8 !Mahler et8al8, .01%


12/27


13/27

CRITERI

A

EVIDENCE

1 +e3ersible symptoms o? parado-ical acute bronchospasm, cough,throat irritation and dry mouth in 0@ but is due to long term use8!uy, .00%

2/3 #n the *ung &ealth Study, mortality and hospitali6ation due to

cardio3ascular disease 4ere highest among patients o mild=to=moderate "$'D using ipratropium8 !Anthonisen et8al8, ..%

T4o large retrospecti3e obser3ational studies ha3e also sho4nthat recent use o ipratropium is associated 4ith an increasedris> o cardio3ascular e3ents and mortality8 !*ee et8al8, .:,.0%

#pratropium use has also been associated 4ith higher ris> o

arrhythmias and stro>e in large retrospecti3e obser3ationalstudies8!Iilches>y, .0.,Iang et8al8, .0.%

4 )ronchodilatory eect may be intensiied by C=adrenergics7


14/27

CRITERIA

EVIDENCE

P

1 Ater inhalation a signicant amount o tiotropiumreaches the systemic circulation, and, as a'o%#e.ue%'e, muscarinic M1 receptors at other sitesin the body 'a% be b(o'"ed +or a% ete%ded time8

The #)#temi' a'ti*it) o+ tiotropium is the cause obothersome side eBects such as dry mouth andconstipation, 4hich ha3e been seen more reKuently4ith tiotropium especially in elderly patients8These arere3ersible and rare or inhalational therapy8!Ied6icha, .01%

2/3 #nhalational *AMAs are relati3ely sae and does notpose any organ to-icity or serious AD+s such as

arrythmia etc8 !!Decramer et8al8, .0G%


15/27

CRITERIA

EVIDENCE

P

1/2/3/4 (ree combinations o *AMA/*A)A also seem4ell tolerated8

No diBerences in blood pressure and pulse rate4ere obser3ed 4ith tiotropium plus salmeterol

3ersus single=agent therapies The meta=analysis o tiotropium plus

ormoterol data reported no diBerences incumulati3e incidence o ad3erse e3ents or thecombination !118.% 3ersus tiotropium alone

!198%, stating that drug=related se3eread3erse e3ents and cardiac eBects 4ererelati3ely rare8 !3an Noord et8al8, .0%

2


16/27


17/27

CRITERIA

EVIDENCE

POT

1/2/4 long=term SAMA monotherapy on regular basis is notrecommended due to its short=lasting orm 4hich4or>s in about 0@ minutes and lasts or 9F: hours,

and is usually ta>en G times a day 4hich diminishespatients compliance to the drug !Hoshar, et8al8,.:< "$'D, .0@%8

3 No contraindication on the patient8 SAMA iscontraindicated in patients 4ith hypersensiti3ity toatropine=li>e substances8 Special precautions in

ta>ing the drug must be gi3en to patients 4ithnarro4=angle glaucoma 7 prostatic hypertrophy,cystic brosis8

2


18/27

CRITE

RIA

EVIDENCE

1 (or both beta.=agonists and anticholinergics, long=actingormulations are preerred o3er short=acting ormulations8!"$'D, .0@%

2Tiotropium bromide, as a monotherapy, is a once=daily,long=acting mA"h+ antagonist !*AMA% 4ith high potencyand >inetic selecti3ity at the mA"h+s8 !)arnes, .

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