COPD case presentation
- 1. COPD case presentation Prepared by: Sara Abudahab, Ala’a Alhayek and Amani Almani Supervised by: Dr. Abla Albsoul Jordan UniversityFaculty of pharmacy
- 2. Outline Patient presentation COPD assessment according to GOLD 2017 Pharmaceutical care plan Smoking cessation Newly approved drugs for COPD References
- 3. Treading on Thin Air Patient Presentation Chief Complaint “My wife says I need to get my lungs checked. Ever since we moved, I’m having a hard time breathing.” HPI D.M is a 59-year-old man who is presenting to a new provider at the family medicine clinic today with complaints of increasing shortness of breath. He points out that he first noticed some difficulty catching his breath at his job 3 years ago. He had been able to carry heavy loads up and down a flight of stairs daily for the last 35 years without any problem. However, his shortness of breath began to make this very difficult. Coincidently at that time, he accepted a managerial position at his company that significantly reduced his activity level.
- 4. Patient Presentation cont. HPI After taking this position, he no longer noticed any problems, but admits that he avoids activities that cause him to physically exert himself. He noticed significant shortness of breath again after he moved to Colorado from a lower elevation 2 months ago to be closer to his grandchildren. His shortness of breath is worst when he is outside playing with his grandchildren. His previous physician had placed him on salmeterol/fluticasone (Advair) one inhalation twice daily 2 years ago. He thinks his physician initiated the medication for the shortness of breath, but he is not entirely sure. He is hoping to get a good medication that will help relieve his shortness of breath because the gardening season is right around the corner, and he enjoys this hobby.
- 5. PMH CAD (MI 7 years ago, resulting in stent placement at that time; additional stent placed 2 years ago; normal ECHO and stress test 3 months ago) Chronic bronchitis × 8 years (has had one exacerbation in the last 12 months; received oral antibiotic treatment but was not hospitalized) Cervical radiculopathy Patient Presentation cont.
- 6. FH Father with COPD (smoked a pipe for 40 years). Mother with coronary artery disease and cerebrovascular disease. SH He lives with his wife, who is a nurse. He has a 40 pack-year history of smoking. When he had an MI at age 52, he quit smoking temporarily. At present, he continues to smoke five to six cigarettes per day. He drinks two to three beers most nights of the workweek. Patient Presentation cont.
- 7. Meds Aspirin 81 mg po once daily Clopidogrel 75 mg po once daily Rosuvastatin 20 mg po once daily Fluticasone/salmeterol 100/50, one inhalation BID OTC ibuprofen 200 mg po four to six times daily PRN neck pain Bupropion SR 150 mg twice daily NKDA Patient Presentation cont.
- 8. ROS (+) Chronic cough with sputum production; (+) exercise intolerance Physical Examination Gen WDWN (well-developed well-nourished) man in NAD (no abnormality detected) VS BP 110/68, P 60, RR 16, T 37°C; Wt 82 kg, Ht 5′9″ (BMI=26.7 i.e overweight); pulse ox 93% on RA Patient Presentation cont.
- 9. Skin Warm, dry; no rashes HEENT Normocephalic; PERRLA, EOMI; normal sclerae; mucous membranes are moist; TMs intact; oropharynx clear Neck/Lymph Nodes Supple without lymphadenopathy Lungs Decreased breath sounds; no rales, rhonchi, or crackles CV RRR without murmur; normal S1 and S2 Patient Presentation cont.
- 10. Abd Soft, NT/ND; (+) bowel sounds; no organomegaly Genit/Rect No back or flank tenderness; normal male genitalia MS/Ext No clubbing, cyanosis, or edema; pulses 2+ throughout Neuro A & O × 3; CN II—XII intact; DTRs 2+; normal mood and affect Patient Presentation cont.
- 11. Lab data Normal Range Na 135 mEq/L 135–145 mEq/L K 4.2 mEq/L 3.3–4.9 mEq/L Cl 108 mEq/L 97–110 mEq/L CO2 26 mEq/L 22–30 mEq/L BUN 19 mg/dL 8–25 mg/dL SCr 1.1 mg/dL 0.7–1.3 mg/dL (male) Glu 89 mg/dL 65–109 mg/dL Hgb 13.5 g/dL 13.8–17.2 g/dL (male) Hct 41.2% 40.7–50.3% (male) Plt 195 × 103/mm3 140–440 × 103/μL WBC 5.4 × 103/mm3 4–10 × 103/mm3 AST 40 IU/L 11–47 IU/L ALT 19 IU/L 7–53 IU/L T. bili 1.1 mg/dL 0.3–1.1 mg/dL Alb 3.8 g/dL 3.5–5.0 g/dL Ca 9.6 mg/L 8.6–10.3 mg/dL Mg 3.6 mg/L (0.36 mg/dL) 1.58–2.68 mg/dL Phos 2.9 mg/dL 2.5–4.5 mg/dL Patient Presentation cont.
- 12. Pulmonary Function Tests (During Clinic Visit Today) Predicted FEV1 is 4.02 L FVC = 4.5 L Prebronchodilator FEV1 = 2.98 L (2.98/4.02= 0.74) Postbronchodilator FEV1 = 2.75 L (2.75/4.02= 0.68) Patient Presentation cont.
- 14. COPD Assessment Tool (CAT)
- 15. mMRC
- 16. COPD Assessment from GOLD 2017
- 17. Pharmacologic treatment according to GOLD 2017 for group B :
- 19. Pharmaceutical Care Plan Date Medical condition TRPs Goal Current Status Interventions Follow-up 5/3/2017 COPD Efficacy More effective drug is available/ recommended The patient requires additional therapy because of actual or potential therapy failure (Fluticasone and Salmetrol) (Bupropion) Reduce Symptoms : Relive symptoms Improve exercise tolerance Improve health status Reduce Risk : Prevent disease progression Prevent and treat exacerbation Reduce mortality Smoking cessation Uncontrolled (GOLD 2 B) (moderate COPD) FEV2 post- bronchodilator = 68% Smoker (5-6 cigarettes day ) Pharmacological 1- D/C Fluticasone and Salmeterol 2- Start Salmeterol (50mcg) 1*2 inhalation/ Tiotropium (Spiriva) 18mcg 1X1 inhalation and Albuterol 90 mcg 1-2 puffs every 4 – 6 hours PRN 3-Clarithromycin 500 mg PO BID for 7-14 days 4-smoking cessation plan DC bupropion start Nicotine RT -improvement symptoms -CAT (2-3 month) -ADRs -Pulmonary function test (spirometry annualy ) -pulse oximetry (O2 sat ) -sputum -Monitor other co -morbidities (CAD) -smoking monitoring 5/3/2017 COPD Inappropriate knowledge The patient does not understand important information regarding his medications (the purpose of his or her medication) (Fluticasone and Salmetrol) The patient is not instructed or does not understand non-pharmacological therapy (smoking ,Vaccinations, weight, exercise) Patient education and Increase knowledge about his medications inhaler technique Decreased exacerbation risk Improve QOL Non-Pharmacological 1-patient education about medication and inhaler technique 2-Smoking cessation 3- Flu vaccine annually and pneumococcal vaccine (PPSV23) 4- pulmonary rehabilitation -medication use inhaler technique -Smoking cessation program monitoring -Frequency of upper respiratory tract infection sputum production – color
- 20. Date Medical condition TRPs Goal Current Status Interventions Follow-up 5-3-2017 CAD IHD Unnecessary drug therapy The patient treatment should be stepped down (Clopidogrel) Avoid adverse treatment effects(bleeding) Stable Pharmacological DC Clopidogrel Bleeding signs Efficacy The patient requires additional because of guidelines recommendation (ACEI B-Blocker Nitroglycerin SL ) Prevent acute coronary syndrome and death Alleviate acute symptoms of myocardial ischemia Prevent recurrent symptoms of myocardial ischemia Prevent progression of the disease Reduce complications of IHD Start 1- ACEI (Enalapril 5 mg 1*1 ) 2-B-Blocker (bisoprolol 5 mg 1*1 ) 3-Nitrpglycerin .3-.4 mg SL PRN Lipid profile Kidney fnction k level ECG O2 sat Inappropriate knowledge The patient is not instructed or does not understand non- pharmacological therapy (smoking ,Vaccinations, weight, exercise) Patient education and Increase knowledge about his medications Non-pharmacological 1-Smoking cessation 2- Flu vaccine annually and pneumococcal vaccine (PPSV23) 3- weight loss aerobic exercise -Smoking cessation program monitoring -Frequency of upper respiratory tract infection Pharmaceutical Care Plan
- 21. Date Medical condition TRPs Goal Current Status Interventions Follow-up 5-3- 2017 Cervical Radiculopathy Efficacy Efficacy interactions issues (aspirin ibuprofen ) D : consider therapy modification Severity : major Stop DDI Increased cardio- protective effect of aspirin stable 1-DC Ibuprofen 2-Start acetaminophen 500 mg *2 PRN 3-Avoide provocated activities rest ice cervical collar gradual movement . Bleeding signs Pain Safety Safety interactions issues (ibuprofen aspirin ) Safety dosage regimen issues (ibuprofen ) Stop DDI Decrease risk of bleeding Prevent ibuprofen ADR ( GIT bleeding AKD CVD ) stable 1-DC Ibuprofen 2-Start acetaminophen 500 mg *2 PRN Pain Pharmaceutical Care Plan
- 23. Smoking cessation cont. 1st line pharmacotherapy for tobacco dependence : Vareniciline Bupropion sustained release Nicotine replacement therapy (gum – inhaler- nasal spray –lozenges- patch ) In COPD patient the probability of sustained abstinence is higher with Nicotine replacement therapy( combination) than sustained release Bupropion In our case we give (nicotine patch 14mg *14 weeks once daily )+(nicotine gum 2 mg one piece every 1-2 hrs ) Reference :Pharmacotherapy principles and practice ( chapter 36 )
- 24. Newly FDA approved medications for COPD
- 25. 1- Bevespi Aerosphere (glycopyrrolate and formoterol fumarate) AstraZeneca; For the treatment of chronic obstructive pulmonary disease, Approved April 2016
- 26. Bevespi Aerosphere MECHANISM OF ACTION : is a combination of glycopyrrolate, an anticholinergic, and formoterol fumarate, a long-acting beta2- adrenergic agonist (LABA).
- 27. Bevespi Aerosphere * Bevespi Aerosphere is specifically indicated for the long- term, maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema. •Bevespi Aerosphere is supplied as an aerosol for oral inhalation. The recommended dose • for the maintenance treatment of COPD is two inhalations twice daily in the morning and in the evening.
- 28. Bevespi Aerosphere side effects: * Urinary tract infection * Cough •Bevespi Aerosphere comes with the following Black Box warning: Long-acting beta2-adrenergic agonists (LABAs), such as formoterol fumarate, one of the active ingredients in Bevespi Aerosphere, increase the risk of asthma-related death. • The safety and efficacy of Bevespi Aerosphere in patients with asthma have not been established. • Bevespi Aerosphere is not indicated for the treatment of asthma.
- 29. Price The cost for Bevespi Aerosphere inhalation aerosol (4.8 mcg-9 mcg/inh) is around $362 for a supply of 10.7 grams
- 30. 2- Stiolto Respimat (tiotropium bromide and olodaterol) Boehringer Ingelheim; For the maintenance of chronic obstructive pulmonary disease, Approved May 2015
- 31. Stiolto Respimat Mechanism of Action Tiotropium is LAMA inhibition of M3-receptors at the smooth muscle leading to bronchodilation. Olodaterol is (LABA). Activation of B2 receptors in the airways results in a stimulation of intracellular adenyl cyclase, an enzyme that mediates the synthesis of(cAMP). Elevated levels of cAMP induce bronchodilation RECOMMENDED DOSE : once-daily fixed-dose combination of tiotropium and olodaterol.
- 32. Stiolto Respimat Side Effects *Adverse reactions associated with the use of Stiolto Respimat may include, but are not limited to, the following: 1. - Nasopharyngitis 2. - cough 3. - Back pain
- 33. Price The cost for Stiolto Respimat inhalation aerosol (2.5 mcg- 2.5 mcg) is around $368 for a supply of 4 grams
- 34. 3- Utibron Neohaler (indacaterol and glycopyrrolate) Novartis; For the long term, maintenance treatment of airflow obstruction in patients with COPD, Approved October 2015
- 35. Utibron Neohaler Mechanism of Action * Utibron Neohaler is a fixed dose combination of glycopyrronium bromide, a once-daily long-acting muscarinic antagonist, and indacaterol, a once-daily long-acting beta-2 agonist.
- 36. Utibron Neohaler * Utibron Neohaler is specifically indicated for the long term, maintenance treatment of COPD. •Utibron Neohaler is supplied as an inhalation powder, for oral inhalation use. The recommended dose •Utibron Neohaler should be administered at the same time of the day, (1 capsule in the morning and 1 capsule in the evening), every day.
- 37. Utibron Neohaler Side Effects * Nasopharyngitis * Hypertension * Utibron Neohaler comes with a black box warning of the potential for long-acting beta2-adrenergic agonists (LABAs) to increase the risk of asthma-related death.
- 38. Price The cost for Utibron Neohaler inhalation capsule (15.6 mcg-27.5 mcg) is around $38 for a supply of 6 capsules
- 39. References GOLD 2017 Pharmacotherapy principles and practice 4 edition Up-to-date AHAACC Drugs.com
Editor's Notes
- #10: HEENT head ear eyes nose throat PERRLA pupils equal, round, react to light, accommodation EOMI Extraocular movements are intact. TM T = Typanic M = Membrane. Absent or Reduced Breath Sounds Reduction in the intensity (loudness) of breath sounds is commonly described as reduced 'air entry'. It can be generalised or localised. Causes of generalised reduction in intensity of breath sounds include: Hyperinflation of the lungs (e.g. COPD), Air gets trapped within the lung and causes it to overinflate. RRR regular rate and rhythm
- #11: NT/ND non tender, non distended alert and oriented to person, place, and time Deep Tendon Reflexes
- #20: Enrollment in a pulmonary rehabilitation program is strongly encouraged; components would include the following: ✓✓Assessment of nutrition and caloric intake ✓✓An exercise program to improve mechanics of breathing ✓✓Psychological education regarding the disease and smoking ✓✓Education regarding pharmacotherapeutic treatment options and the proper use of medications In general, long-acting bronchodilators, such as tiotropium, are preferred in patients with COPD over ipratropium, because of the need for less frequent dosing (once daily vs. four times daily).