respiratory update: guidelines, novel inhalers and more · astrazeneca lp. 4 disclosures ......

© 2016 by the American Pharmacists Association. All rights reserved.

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Respiratory Update: Guidelines, Novel Inhalers and More

Dennis Williams, PharmD, BCPS, FAPhA

University of North Carolina Eshelman School of Pharmacy

Chapel Hill, North Carolina

Michael J. Cawley, PharmD., RRT, CPFT, FCCM

Philadelphia College of Pharmacy / University of the Sciences

Philadelphia, PA

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Supporter

• Supported by an independent educational grant from AstraZeneca LP.

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Disclosures

• Dennis Williams reports that his spouse is an employee of GlaxoSmithKline and also holds stock in the company

• Michael J. Cawley: “declare(s) no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.”

The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

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• Target Audience: Pharmacists

• ACPE#: 0202-0000-16-050-L01-P

• Activity Type: Application-based

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Learning Objectives• Classify symptom severity, assess control, and select and

monitor appropriate therapy for patients with asthma or COPD

• Given representative patient cases, develop care plans for patients with asthma or COPD based on current guidelines for assessing and treating patients

• Discuss current and emerging therapeutic options for the management of asthma and COPD

• Discuss patient related factors to consider when selecting among available inhaler devices

• Demonstrate how to use devices for the management of asthma and COPD and educate patients on proper use


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The most important and prognostic spirometry parameter to assess in COPD for disease severity and progression is the

A. Peak expiratory flow rate (PEF)

B. Forced vital capacity (FVC)

C. Forced expiratory volume in 1 second (FEV1)

D. Residual volume (RV)

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The frequency of use of which of the following medications is a good indicator of current asthma control?

A.Budesonide

B.Salmeterol

C.Albuterol

D.Montelukast

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Foundational treatment for asthma focuses on _______ therapy and the focus of COPD treatment is on ___________therapy.

A. Bronchodilator, corticosteroid

B. Bronchodilator, bronchodilator

C. Corticosteroid, bronchodilator

D. Corticosteroid, corticosteroid

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Which of the following therapeutic options is FDA approved for both asthma and COPD?

A. Tiotropium (Spiriva Respimat)

B. Aclidinium (Tudorza Pressair)

C. Umeclidinium (Incruse Ellipta)

D. Albuterol/Ipratropium (Combivent)

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Which of the following is/are patient related factors to consider when selecting an inhaler device?

A. Age, physical and cognitive abilities

B. Availability of drug

C. Cost of the drug and device

D. All of the above

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Asthma

• Asthma is a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms

• Features of asthma include– airflow obstruction– bronchial hyperresponsiveness– inflammation

• The interaction of these features of asthma determines the clinical manifestations and severity of asthma and the response to treatment


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Asthma PathophysiologySusceptible Person

is Exposed to Trigger

Airway Mucosal Inflammation Airway

Hyperresponsiveness

BronchospasmAirway

HyperreactivityIncreased Mucus

Production

WheezingCough

Shortness of BreathChest Tightness

Causing

Numerous Cells and Mediators

are Activated

Leading To

Resulting In

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Clinical Management of Asthma

Source: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

EPR 3; NAEPP; NHLBI 2007

GINA Guidelines;NHLBI and WHO2015

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Robin

• Robin is an 11 year old Caucasian male who is brought to the clinic by his parents after a visit to the emergency department last evening because of an acute asthma episode

• He was treated with albuterol and oxygen and discharged on an albuterol MDI and prednisone for 5 days, and advised to come to the clinic today

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Robin

• According to his parents, the patient developed a head cold about 3 days prior which moved into his chest

• Yesterday, he began coughing and complaining of chest tightness and shortness of breath

• His parents could hear wheezing in his chest and took him to the emergency department

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Robin

• His PMH is relatively unremarkable. He has had nasal allergies since age 7 for which he uses loratadine as needed. His mom feels that his allergies are more of a problem in the spring when the pollens are present.

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Robin

• He is a moderately obese male, 50 kg and 56 inches tall who appears healthy and in NAD

• Vitals are WNL and he is afebrile

• Scattered and diffuse wheezes are present on auscultation

• Peak flow is measured at 235 (predicted is 300). Spirometry is not performed

• Pulse oximetry is 96%


19EPR-3, Oct 2007. NIH Pub # 08-5846 http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf

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What should be considered now regarding therapy?A. Continue chronic low dose

prednisone

B. Start an inhaled corticosteroid

C. Start a leukotriene modifier

D. Continue the rescue inhaler and monitor

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Robin

• The family is advised to finish the prednisone, use albuterol for any subsequent symptoms and to RTC in one month

• He is also instructed to continue to use his loratadine when needed

• The patient is a no show for his one month followup

• A refill request for albuterol is received at 6 weeks

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EPR-3, Oct 2007. NIH Pub # 08-5846 http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf

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Robin

• The family is contacted and returns for a visit

• They report that Robin has not experienced any more episodes as severe as before

• He has experienced some shortness of breath with physical activity but the albuterol seems to help with that

• He wakes up about once a week or less complaining of shortness of breath but returns to sleep after using his inhaler

• His peak flow in the clinic is 270

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What’s the best action now?

A.Refill the albuterol

B.Switch to levalbuterol

C.Start salmeterol

D.Consider a long term control therapy


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Stepwise treatment, Ages 5-11

Adapted from EPR-3, Oct 2007. NIH Pub # 08-5846 http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf 26

Components of Asthma Management

• Assessment and monitoring

• Patient education

• Control of environmental factors and comorbid conditions

• Pharmacotherapy

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Asthma: Assessment and Monitoring Check Points

• Adherence with therapy

• Optimal inhalation technique

• Avoidance of triggers and aggravating conditions

• Vaccines up to date

• Provision of asthma action plan

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EPR-3, Oct 2007. NIH Pub # 08-5846 http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf

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Bob• Bob Davis is a 34 year old male with mild persistent

asthma treated with budesonide 180 mcg twice daily and PRN albuterol. He indicates that he has had mild asthma his entire life and that the only thing that makes it worse is cigarette smoke. Sometimes he gets symptoms with exercise which he doesn’t do very often.

• He feels that his asthma was well controlled in the past and estimates that he uses his albuterol 3 or 4 times a month.

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More about Bob

• Recently, he has noticed that his symptoms are occurring more frequently, requiring him to use albuterol almost daily. The increased symptoms are limiting his ability to exercise and play tennis.

• Last evening, his symptoms acutely worsened and he went to an urgent care center where he received nebulized albuterol and a 5 day course of prednisone 40 mg.


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EPR-3, Oct 2007. NIH Pub # 08-5846 http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf 32

What advice is appropriate for Bob now?

A.Hang in there and tough it out

B. Increase the budesonide

C.Add a LABAD.Add a leukotriene

modifier

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Asthma: Assessment and Monitoring Check Points

• Adherence with therapy

• Optimal inhalation technique

• Avoidance of triggers and aggravating conditions

• Vaccines up to date

• Provision of asthma action plan

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Intermittent Asthma

Persistent Asthma: Daily MedicationConsult with asthma specialist if step 4 or higher care is required

Consider consultation at step 3

Provide Patient Education and Environmental Control Advice at Each Step

Step 1Preferred:SABA prn

Step 2Preferred:

Low-dose ICSAlternative:

LTRACromolyn

Theophylline

Step 3Preferred:

Low-dose ICS+LABA

ORMedium-dose

ICSAlternative:

Low-dose ICS+ either

LTRA, TheophyllineOr Zileuton

Step 4

Preferred:Medium-dose

ICS+LABA

Alternative:Medium-dose

ICS+eitherLTRA,

TheophyllineOr Zileuton

Step 5Preferred:

High dose ICS+ LABA

AND

ConsiderOmalizumab for

patients withallergies

Step 6

Preferred:High-dose ICS+ LABA + oralCorticosteroid

AND

ConsiderOmalizumab for

patients withallergies

AssessControl

Stepwise Approach to Managing Asthma in Individuals ≥12 Years of Age

Step up if needed

(check adherence,

environment-al control

and co-morbidities)

Step down if possible(asthma well

controlled for 3 months)

Adapted from National Heart, Lung and Blood Institute. EPR 3 Guidelines; 2007.

Or ICS/tiotropium Or add tiotropium to ICS/LABA

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Options for Bob

• Add LABA to ICS therapy

• Increase ICS dose

• Add a leukotriene modifier

• Add tiotropium

• Monitor for effectiveness and safety

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What vaccines should be considered for Bob based on his asthma diagnosis?A. Influenza

B. Pneumococcal

C. Hepatitis B

D. All of the above

E. Both 1 and 2 above


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Chronic Obstructive Pulmonary Disease

“Chronic Obstructive Pulmonary Disease (COPD), a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.”

2013 GOLD Guidelines. www.goldcopd.org38

Inflammation in COPD

GeneratesBurning

Hydrocarbons Respiratory Tract Macrophages

Activates

Neutrophils

Release

Release

Proteases

Airway and ParenchymalDamage

Resulting in

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Ray—The Case Study

• Ray is a 63 year-old male known to have COPD who visits his clinician because he feels that his albuterol/ipratropium inhaler is not working well

• The patient was diagnosed with COPD five years ago attributed to a 48 pack year smoking history (Continues to smoke about ¾ PPD)

• Patient is s/p MI three years ago and treated with metoprolol, lisinopril, and furosemide

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Ray—The Case Study• Over the past few months, Ray has noticed decreased exercise

tolerance

• He gets SOB easily and feels that his albuterol/ipratropium is not working as well as it has in the past. He uses it PRN and has often required it three or four times daily

• He has not been hospitalized or in the ED because of his COPD

• His physical exam is relatively unremarkable and his chest x-ray shows some scarring consistent with his tobacco history

• Pulse oximetry is 91% and spirometry reveals:

– FEV1 is 2.4 L (72% predicted); FVC is 3.49 L (85% predicted) with a ratio of 69%

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Global Initiative for Chronic Obstructive Pulmonary Disease

• Available at www.goldcopd.com

• First version published in 2001

• Most recent update: 2015

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Combined Assessment of COPD

• Three components determine severity – Spirometry to assess degree of airflow limitation

– Symptoms assessment (various tools)

– Risk for exacerbations


FEV1/FVC < 0.70

FEV1 <30% predicted OR

FEV1 <50% predicted

PLUS chronic respiratory

failure

FEV1/FVC < 0.70

FEV1 ≥ 80% predicted

Spirometry is essential for diagnosis of COPD and monitoring progression

I: Mild II: Moderate III: Severe IV: Very Severe

FEV1/FVC < 0.70

50% ≤ FEV1 < 80% predicted

FEV1/FVC < 0.70

30% ≤ FEV1 < 50% predicted

Post-bronchodilator FEV1 is recommended for the assessment of COPD severity

American Thoracic Society, European Respiratory Society. Standards for the diagnosis and Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPD. Updated 2015 44

Global Strategy for Diagnosis, Management and Prevention of COPD

Combined Assessment of COPD

© 2014 Global Initiative for Chronic Obstructive Lung Disease

Risk

(GOLD

Classification of Airflow Lim

itation)

Risk

(Exacerbation history)

≥ 2or> 1 leadingto hospitaladmission

0‐1 (not leading to hospitaladmission)

Symptoms

(C) (D)

(A) (B)

CAT < 10

4

3

2

1

CAT > 10

BreathlessnessmMRC 0–1 mMRC > 2

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MMRC Questionnaire: Breathlessness Self-Assessment

Severity Score Level of Breathlessness

None 0 Only breathlessness with strenuous exercise

Mild 1 Short of breath hurrying or walking up a slight hill

Moderate 2 Walks slower than age group or has to stop for breath when walking on the level at own pace

Severe 3 Stops for breath after walking 100 meters or a few minutes on the level

Very Severe 4 Breathless when dressing/undressing or too breathless to leave the house

MMRC patient questionnaire available at http://copd.about.com

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COPD Assessment Test™ (CAT)*• Eight questions; 5-point scale • (0 = least severe; 5 = most severe)

– Cough– Phlegm (mucus)– Chest tightness– Breathless walking up a hill or one flight of stairs– Activity limitations– Confident to leave home– Sleep– Energy

• Assessment– Minimum score: 0– Maximum score: 40

* This assessment tool is a trademark of the GlaxoSmithKline group of companies.

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Treatment Goals: Stable COPD

Reduce Symptoms

• Relieve symptoms

• Improve exercise tolerance

• Improve overall health status

Reduce Risks

• Prevent disease progression

• Prevent and treat exacerbations

• Reduce mortality

• Prevent and treat complications

• Minimize side effects

2013 GOLD Guidelines. www.goldcopd.org 48

What is your recommendation for Ray?

A. Add tiotropium

B. Add salmeterol

C. Continue albuterol/ipratropium

D. Add budesonide/formoterol


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Pharmacotherapy Recommendations for COPDPatient Group (Classification)

Recommended 1st

ChoicesAlternative Choices Other Options

A • Short-acting anticholinergic PRN

• Short-acting β2 agonist PRN

• Long-acting anticholinergic• Long-acting β2 agonist • Short-acting β2 agonist and

short-acting anticholinergic in combo

• Theophylline

B • Long-acting anticholinergic

• Long-acting β2 agonist

• Long-acting anticholinergicplus

Long-acting β2 agonist

• Short-acting anticholinergic PRN


• Combo of two above• Theophylline

C • Inhaled corticosteroid plus long-acting β2 agonist

• Long-acting anticholinergic

• Long-acting anticholinergicplus

Long-acting β2 agonist

• Either of the above agents with phosphodiesterase-4inhibitor

• Short-acting anticholinergic PRN


• Combo of two above• Theophylline

D • Inhaled corticosteroid plus long-acting β2 agonist

• Long-acting anticholinergic• Combo of both above

• Inhaled corticosteroid plus long-acting β2 agonist and long-actinganticholinergic

• Inhaled corticosteroid plus long-acting β2 agonist and phosphodiesterase-4 inhibitor

• Long-acting anticholinergic and long-acting β2 agonist

• Long-acting anticholinergic plus phosphodiesterase-4 inhibitor

• Short-acting β2 agonist• Short-acting anticholinergic• Combo of two above• Carbocysteine• Theophylline

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Summary

• National and international guidelines are available for advice about managing asthma and COPD

• Numerous therapeutic options exist for each condition

• The focus of asthma therapy is on corticosteroids while COPD focuses on bronchodilators

• Inhalational routes are the preferred and common methods for managing asthma and COPD

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Patient Case• Richard is a 54-year-old male with COPD presents to his

family physician with increased SOB over the past 2 weeks

• Medical problems include hyperlipidemia and broken right arm (full arm cast) due to recent construction accident

• Smoker (36 pack year history)

• Occupational history as a construction laborer x 20 years

• Presently the patient is prescribed an albuterol inhaler PRN and simvastatin 20 mg daily

• Patient received both influenza and pneumococcal vaccine last month

SOB = shortness of breath; PRN = as needed.

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Patient Case (cont.)• Over the past few weeks, his SOB has increased,

requiring use of his albuterol inhaler up to 4x per day, with some relief

• He has required 3 hospital visits due to his breathing within the last 12 months

• His physical exam is unremarkable; however, during auscultation and percussion, a decrease in breath sounds is noted

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Which of the following would be required to determine a category assessment of COPD?

A. Spirometry testing

B. History of COPD exacerbation

C. CAT score

D. All of the above

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Current and Emerging Therapeutic Options for Asthma and COPD


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Current Inhaled Medications for Asthma/COPDMedication Brand Starting Dose (inhalations) Asthma / COPD

β2-Agonists

Short-acting

Albuterol ProAir, Proventil, Ventolin, ProAirRespiClick

2 q 4-6 hrs Asthma/COPD

Levalbuterol Xopenex HFA 2 q 4-6 hrs Asthma

Long-acting

Formoterol Foradil Aerolizer, Perforomist, Brovana

1 inh cap bid Asthma/COPD

Indacaterol Arcapta Neohaler 1 inh cap daily COPD

Salmeterol Serevent Diskus 1 bid Asthma/COPD

Olodaterol Striverdi Respimat 2 once daily COPD

HFA = hydrofluoroalkane; Food and Drug Administration. Drugs@FDA. https://www.accessdata.fda.gov/scripts/cder/drugsatfda/

Accessed November 201556

Current Inhaled Medications for Asthma/COPDMedication Brand Starting Dose

(inhalations)Asthma/COPD

Anticholinergics

Ipratropium Atrovent 2 qid COPD

Aclidinum Tudorza Pressair 1 bid COPD

Tiotropium Spiriva HandiHalerSpiriva Respimat

1 inh cap daily2 daily

COPDAsthma/COPD

Umeclidinium Incruse Ellipta 1 daily COPD

Glycopyrrolate Seebri Neohaler 1 inh cap bid COPD

Combination agents

Albuterol/ipratropium Combivent 2 q4-6 hrs COPD

Umeclidinum/vilanterol Anoro Ellipta 1 daily COPD

Olodaterol/tiotropium Stiolto Respimat 2 daily COPD

Indacaterol/glycopyrrolate Utibron Neohaler 1 inh cap bid COPD

Food and Drug Administration. Drugs@FDA. https://www.accessdata.fda.gov/scripts/cder/drugsatfda/


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Current Inhaled Medications for Asthma/COPDMedication Brand Starting Dose

(inhalations)Asthma/COPD

Inhaled Corticosteroids

Budesonide PulmicortFlexhaler

1-2 bid Asthma/COPD

Fluticasone Flovent HFA 1-2 bid Asthma/COPD

Beclomethasone QVAR 1-2 bid Asthma/COPD

Ciclesonide Alvesco 1-2 bid Asthma/COPD

Combination Inhalers

Formoterol/budesonide Symbicort 2 bid Asthma/COPD

Mometasone/formoterol Dulera 2 bid Asthma

Fluticasone/salmeterol Advair DiskusAdvair HFA

1 bid2 bid

Asthma/COPD

Fluticasone/vilanterol Breo Ellipta 1 daily Asthma/COPD

HFA = hydrofluoroalkane; Food and Drug Administration. Drugs@FDA. https://www.accessdata.fda.gov/scripts/cder/drugsatfda/


Current Oral Medications for Asthma/COPD

Medication Brand Usual Starting Dose Asthma/COPD

Corticosteroids

Methylprednisolone 4-48mg/day depending on disease and response

Asthma/COPD

Prednisolone 5-60mg/day depending on disease and response

Asthma/COPD

Prednisone 5-60mg/day depending on disease and response

Asthma/COPD

PDE4 Inhibitor

Roflumilast Daliresp One 500 mcg tablet by mouth daily

COPD

Food and Drug Administration. Drugs@FDA. https://www.accessdata.fda.gov/scripts/cder/drugsatfda/


59

Respiratory Delivery Devicesand Proper Inhaler Technique

60

Incorrect Inhaler Technique• 28-68% of patients do not use MDIs or DPIs correctly

• Even with optimal use of any aerosol delivery system, lung deposition may range from 10-15% of the total medication dose

• Worsening pulmonary symptoms may not always indicate disease progression but may indicate inability to use inhaler device optimally

• Instructing patient in the essential steps in drug delivery with device and observe patient demonstrating are key factors for patient success

American Association for Respiratory Care Guide to Aerosol Delivery Devices.

https://c.aarc.org/resources/aerosol_nonrts.pdf. Accessed Nov 2015


61

Errors with Specific Inhaler Devices• pMDI

– Failure to shake and prime the device

– Failure to coordinate pMDI depression (actuation) on inhalation

• pMDI with spacer

– Delay between actuation and inhalation

• Dry-powder inhalers

– Failure to pierce or open drug package

– Exhaling through the mouthpiece

– Not inhaling forcefully enoughAmerican Association for Respiratory Care Guide to Aerosol Delivery Devices. https://c.aarc.org/resources/aerosol_nonrts.pdf. Accessed Nov 2015 62

Criteria for Selecting an Aerosol Delivery Device

• Patient related factors

– Age, physical and cognitive abilities

• Drug related factors

– Availability of drug

– Combination of aerosol treatments

• Device related factors

– Convenience, durability, cost and reimbursement of aerosol generator

• Environmental and clinical factors

– When and where aerosol therapy is required

American Association for Respiratory Care Guide to Aerosol Delivery Devices. https://c.aarc.org/resources/aerosol_nonrts.pdf. Accessed Nov 2015

63

Respiratory Delivery Devices

ProAir RespiClick (albuterol sulfate)

RxList: The internet drug indexhttp://www.rxlist.com/proair-respiclick-drug/medication-guide.htm 64

Respiratory Delivery Devices

HandiHaler (tiotropium bromide)

2

1

5

4

3

1. Dust cap

2. Mouthpiece

3. Base

4. Green piercing button

5. Center chamber

Personal photograph: September 2015

65

Respiratory Delivery DeviceBreo Ellipta (fluticasone furoate/vilanterol)Incruse Ellipta (umeclidinium)Anoro Ellipta (umeclidinium/vilanterol)

Mouthpiece

Counter

Air Vent

Cover

Personal Photograph: September 201566

Respiratory Delivery DeviceArcapta Neohaler (indacaterol inhalation powder)Seebri Neohaler (glycopyrrolate)Utibron Neohaler (indacaterol/glycopyrrolate

Personal Photograph: August 2015


67

Respiratory Delivery Device

Turn transparent base until it clicks

Insert mouthpiece into mouth and while taking a deep breath, press the dose-release button and continue to breathe in.

Stiolto Respimat (olodaterol/tiotropium)

Mouthpiece

Cap

Dose release button

Cartridge

Transparent base


Respiratory Delivery Device• Respimat Soft Mist Inhaler

Food and Drug Administration. Drugs@FDA. http://www.accessdata.fda.gov/scripts/cder/ drugsatfda/index.cfm. http://experts.respimat.com/functions_and_use/components_of_Respimat.html

69

Respiratory Delivery Device

Tudorza Pressair (aclidinium bromide)

Dose button

Dose indicator

Colored dose window

Mouthpiece

Protective Cap


Clinical Case – Back to Richard

Richard has improved with the addition of fluticasone/vilanterol inhaler, however is still needing to use his albuterol 3x daily.

The pharmacist recommends adding a long‐acting anticholinergic to his present regimen

71

Which of the following long‐acting anticholinergics would be the most optimum selection(s) for Richard at this time?

A. Tiotropium (Handihaler) or umeclindinium

B. Tiotropium (Respimat) or umeclindinium

C. C. Aclidinium or umeclindinium

D. D. All of the above

72

Question – Follow‐up

A B

CD

Richard has a broken right arm. Inserting medication capsule in device A or twisting device B would be difficult.

Pushing the button of device C or opening cover of device D would be most optimum.

HandiHaler Respimat

Tudorza / PressairEllipta


73

Common Errors with Inhalers

• Unfamiliar with device

• Failure to hold breath for sufficient time after drug delivery

• Multiple actuations without waiting or shaking in between doses

• Incorrect position of device

• Failure to breathe deeply and with enough force to deliver medication (dry power inhalers)

• Exhaling into device

American Association for Respiratory Care Guide to Aerosol Delivery Devices. https://c.aarc.org/resources/aerosol_nonrts.pdf. Accessed October, 2015

74

Inhaler Use – House MD

https://www.youtube.com/watch?v=nvwR74XpKUM

75

Strategies for Correct Inhaler Technique• Review device instructions and practice with placebo device

• Demonstrate assembly and correct use of device using a checklist

• Provide the patient written instructions on how to use the device

• Have patient practice using the device while being observed

• Review patients understanding of the inhaled medication at each return visit (when to use, purpose of drug, prescribed frequency)

• If poor management of airway disease occurs suspect incorrect use or non-adherence

American Association for Respiratory Care Guide to Aerosol Delivery Devices. https://c.aarc.org/resources/aerosol_nonrts.pdf. Accessed October, 2015

76

Potential Roles for Pharmacists in Assisting Patients With Asthma and COPD

• Help identify existing asthma “triggers” and how to avoid them

• Create an asthma control plan with physician

• Advising and assisting with tobacco cessation

• Recommending and administering vaccines

• Monitoring and educating to improve adherence and correct inhaler technique

• Ensuring optimal pharmacotherapy to meet goals

• Providing medication therapy management services

• Performing spirometry testing

American Pharmacists Association Foundation. J Am Pharm Assoc. 2011;51(2):203-211. Cawley MJ, et al. J Am Pharm Assoc. 2013;53(3):307-315

77

Key Points

• Asthma and COPD are chronic respiratory diseases requiring a focus on preventing exacerbations and maintaining improved quality of life

• Selection of appropriate pharmacotherapy and inhalational device is an essential component of management

• Pharmacists should continually educate themselves on new pharmacotherapeutic options and aerosol delivery devices

• Pharmacists must work with patients to assist with aerosol delivery device technique and strategies to maintain compliance

78

The most important and prognostic spirometry parameter to assess in COPD for disease severity and progression is the

A. Peak expiratory flow rate (PEF)

B. Forced vital capacity (FVC)

C. Forced expiratory volume in 1 second (FEV1)

D. Residual volume (RV)


79

The frequency of use of which of the following medications is a good indicator of current asthma control?

A.Budesonide

B.Salmeterol

C.Albuterol

D.Montelukast

80

Foundational treatment for asthma focuses on _______ therapy and the focus of COPD treatment is on ___________therapy.

A. Bronchodilator, corticosteroid

B. Bronchodilator, bronchodilator

C. Corticosteroid, bronchodilator

D. Corticosteroid, corticosteroid

81

Which of the following therapeutic options is FDA approved for both asthma and COPD?

A. Tiotropium (Spiriva Respimat)

B. Aclidinium (Tudorza Pressair)

C. Umeclidinium (Incruse Ellipta)

D. Albuterol/Ipratropium (Combivent)

82

Which of the following is/are patient related factors to consider when selecting an inhaler device?

A. Age, physical and cognitive abilities

B. Availability of drug

C. Cost of the drug and device

D. All of the above

respiratory update: guidelines, novel inhalers and more · astrazeneca lp. 4 disclosures ......

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