smoking cessation and chronic obstructive pulmonary disease (copd) management stephanie cox, pharmd,...

Smoking Cessation and Chronic Obstructive Pulmonary Disease (COPD) Management

Stephanie Cox, PharmD, PGY2 Ambulatory Care ResidentRachel Lee, PharmD, PGY1 Pharmacy ResidentShelby Williams, PharmD, PGY1 Pharmacy Resident

May 29, 2015

VETERANS HEALTH ADMINISTRATION 2

Disclosure Statement

• Disclosure statement: these individuals have the following to disclose concerning possible financial or personal relationships with commercial entities (or their competitors) that may be referenced in this presentation

- Resident: Stephanie Cox, Pharm.D. – nothing to disclose

- Resident: Rachel Lee, Pharm.D. - nothing to disclose

- Resident: Shelby Williams, Pharm.D. – nothing to disclose


Objectives

• Explain non-pharmacological and pharmacological treatment options for smoking cessation

• Discuss current chronic obstructive pulmonary disease (COPD) guidelines

• Demonstrate proper inhaler administration technique

• Discuss counseling guidelines for the commonly used inhalers for COPD treatment

Smoking Cessation


Smoking Rates

• About 1 in 5 American adults smoke cigarettes (17.8%)

• Smoking rate is higher among some Veterans than the general population

• Annual smoking-attributable cost in the U.S. for direct medical care between 2009-2012 was $132.5-175.9 billion

Smoking-Attributable Morbidity, Mortality, and Economic Costs. http://www.surgeongeneral.gov/library/reports/50-years-of-progress/sgr50-chap-12.pdf. Accessed May 15, 2015. Brown, DW. J Gen Intern Med 25(2): 147-9.


Consequences of Smoking

• Leading preventable cause of death – accounts for 1 of every 5 deaths

• COPD is about 4 times more prevalent among Veterans than the general population

CDC. Annual Deaths Attributable to Cigarette Smoking—United States. http://www.cdc.gov/tobacco/data_statistics/tables/health/attrdeaths/index.htm. Accessed May 2015.COPD: Challenges and Opportunities for Federal Medicine. COPD Prevalence among Veterans Related to High Smoking Rates. U.S. Medicine.


COPD Statistics and Prevention

• About 12 million Americans have COPD and another 12 million may be undiagnosed

• In 2010, the cost of COPD in the U.S. was $50 billion

• COPD has a major negative impact on quality of life

• 75% of COPD cases are attributable to cigarette smoking, therefore must focus on prevention– Reduce or eliminate smoking initiation by young adults– Encourage tobacco cessation among current smokers

Public Health Strategic Framework for COPD Prevention. www.cdc.gov/copd/pdfs/Framework_for_COPD_Prevention.pdfClinicoecon Outcomes Res. 2013; 5: 235–245.


Smoking Cessation Problems

• Chronic disease – requires repeated intervention and multiple attempts to quit

• Many patients try to quit smoking without counseling/pharmacotherapy– Most are unsuccessful– Encourage patients to use these to improve success

• Physicians, pharmacists, and nurses are in a great position to intervene during patient care visits– Physician’s advice is an important motivator

Treating Tobacco Use and Dependence. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/index.html.


Smoking Cessation Options

• Intervention by physicians– Provide a brief period of counseling (three minutes or less) – Common approach to effective intervention

• Counseling– Group or individual– Repeated contacts over at least four weeks

• Pharmacotherapy

• Both counseling and pharmacotherapy are each effective, but the two in combination achieve the highest rates of smoking cessation

Treating Tobacco Use and Dependence. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/index.html.N Engl J Med 2002; 346:506-512.


Assessment during Patient Visits - NEJM

Ask patient whether he or she smokes

If the answer is “Yes”

Offer personalized advice about stopping smoking (e.g. “Quitting smoking is the most important

action you can take to stay healthy”)

Determine whether the patient is interested in quitting at this time

Rigotti, NA. N Engl J Med 2002; 346:506-512.



If the answer is “Yes, in the next 30 days”

• Ask smoker to set a quit date

• Assess prior efforts:– “What have you tried?”– “What worked?”– “What didn’t work?”

• Help smoker make a plan:– Offer pharmacotherapy– Offer behavioral support

• Referral to counseling program (telephone or in person)• On-line resources

• Express confidence in the smoker’s ability to quit



Assessment during Patient Visits - NEJMIf the answer is “Yes, but not now”

• Identify and address barriers to quitting:– Nicotine dependence– Fear of failure– Lack of social support (friends and family smoke)– Little self-confidence in ability to stop smoking– Concern about weight gain– Depression– Substance abuse

• Identify reasons to quit:– Health related– Other

• Ask patient to set a quitting date




If the answer is “No”

• Use motivational strategies:– Avoid argument– Acknowledge smoker’s ambivalence about quitting– Elicit smoker’s view of the pros and cons of smoking and smoking

cessation– Correct smoker’s misconceptions about health risks of smoking and

the process of quitting smoking

• Discuss risks of passive smoking for family and friends• Offer to help smoker when he or she is ready to quit



Pharmacotherapy Options

• Nicotine replacement therapy (NRT)– Temporarily replaces some of the nicotine from cigarettes to reduce

motivation to smoke and nicotine withdrawal symptoms– Examples: Patch, gum, lozenge

• Bupropion– May block nicotine effects, relieving withdrawal and reducing

depressed mood

• Varenicline (Chantix)– Helps by maintaining moderate levels of dopamine to counteract

withdrawal symptoms and reducing smoking satisfaction

Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.


Treatment Efficacy

• Dual NRT (more effective than single NRT)– Nicotine patch + nicotine gum– Nicotine patch + nicotine lozenge

• Nicotine patch + bupropion SR

• Varenicline (Chantix)

• All 3 options are proven effective options

Treating Tobacco Use and Dependence. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/index.html.Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.


Nicotine Patch• Dosing: number of cigarettes smoked per day

• Pharmacotherapy pearls:– Apply a new patch every 24 hours

• If nightmares occur, may remove the patch before bed each night– Takes a few hours to reach peak levels

• Side effects: skin sensitivity and irritation (usually mild)

# of Cigarettes/day Patch Dosing> 10 cigarettes/day 21 mg/day x 4 weeks, then

14 mg/day x 2 weeks, then 7 mg/day x 2 weeks

≤ 10 cigarettes/day OR < 45 kg body weight

14 mg/day x 6 weeks, then7 mg/day x 2 weeks

Nicoderm CQ [package insert]. GlaxoSmithKline. Moon Township, PA. 2014.Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.


Nicotine Gum

• Dosing: number of cigarettes smoked each day

• Pharmacotherapy pearl: “chew and park” for 30 minutes• Side effects: hiccoughs, GI disturbances, jaw pain, and orodental problems

# of Cigarettes/day Dose≥ 25 cigarettes/day 4 mg every 1-2 hours for 6 weeks, then

gradually reduce over an additional 6 weeksMax: 24 pieces/day

< 25 cigarettes/day 2 mg every 1-2 hours for 6 weeks, then gradually reduce over an additional 6 weeksMax: 24 pieces/day

Sunmark Nicotine [package insert]. GlaxoSmithKline. Moon Township, PA. 2014. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.


Nicotine Lozenge

• Dosing: timing of first cigarette of day

• Pharmacotherapy pearl: dissolve over 30 minutes• Side effects: hiccoughs, burning and smarting sensation in the mouth, sore

throat, coughing, dry lips and mouth ulcers

Timing DoseFirst cigarette < 30 minutes after awakening

4 mg every 1-2 hours for 6 weeks, then gradually reduced over an additional 6 weeksMax: 5 lozenges every 6 hours or 20 per day

First cigarette ≥ 30 minutes after awakening

2 mg every 1-2 hours for 6 weeks, then gradually reduced over an additional 6 weeksMax: 5 lozenges every 6 hours or 20 per day

Nicorette – nicotine lozenge. [package insert]. GlaxoSmithKline. Moon Township, PA. 2014. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.


Bupropion SR

• Dosing: 150 mg/day x3 days, then 150 mg twice daily for at least 12 weeks

• Pharmacotherapy pearls:– Usually started 5-7 days prior to patients quit date– May blunt weight gain associated with smoking cessation

• Side effects:– Insomnia (30-40%)– Dry mouth (10%)– Nausea (< 10%)– Seizures (less common)

• Use caution in patients with a history of seizures

Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.


Varenicline (Chantix)

• Restricted to CARP

• Dosing: – Week 1 (titration)

• Days 1-3: 0.5 mg tablet every day• Days 4-7: 0.5 mg tablet twice daily

– Weeks 2-12• 1 mg tablet twice daily

• Side effects: nausea (30%), abnormal dreams, headache

• Cautions:– Neuropsychiatric symptoms– Seizures– Increased intoxicating effects of alcohol– Cardiovascular events (patients with known cardiovascular history)

Chantix [package insert]. Pfizer Labs. New York, NY. Feb 2015.Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.


Recommendations

• Spend the extra few minutes to discuss smoking cessation

• If patients are ready, refer for counseling or the smoking cessation class

• Offer pharmacotherapy, including dual NRT or nicotine patch plus bupropion SR – use the clinical reminder to order medications

• Ensure patients are receiving the correct amounts of pharmacotherapy

COPD GuidelinesGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2015

22


Diagnosing COPD

• Indicators of COPD– Dyspnea, chronic cough, chronic sputum production,

family history– Exposure to risk factors

• Clinical diagnosis– Spirometry • Post-bronchodilator FEV1/FVC <0.70

Global initiative for chronic obstructive lung disease (GOLD). 2015. COPD, INC.


Assessment of COPD

• Symptoms– COPD Assessment Test (CAT)– Modified British Medical Research Council (mMRC) scale

• Exacerbation

Symptoms Score

Less symptoms mMRC 0-1 or CAT <10

More symptoms mMRC ≥ 2 or CAT ≥10

risk # exacerbation/ year or hospitalization

Low ≤ 1 or no hospitalization for exacerbation

High ≥ 2 and ≥ 1 hospitalization for exacerbation


Assessment of COPD

• Severity level

Gold level Severity FEV1 Predicted1 Mild ≥ 80%2 Moderate 50-79%3 Severe 30-49%4 Very severe <30%


Combined Assessment


Pharmacologic Treatments

Broadwith, P. New respiratory drugs neck and neck. Royal Chemistry Society. 2015

VETERANS HEALTH ADMINISTRATION

Beta 2-Agonists

• Mechanism of Action (MOA): Binds to beta-2 receptors on the bronchial smooth muscle to induce bronchodilation

• Adverse effects: cardiac rhythm disturbance and tremor

Generic Brand Formulations DOA (hours)

Short actingalbuterol Proventil HFA Inhaler, Neb, tablet 4-6levalbuterol (NF) Xopenex Inhaler, Neb 6-8

Long acting formoterol (R) Preforomist Inhaler, Neb 12salmeterol (NF) Serevent Inhaler 12arformoterol (NF) Brovana Neb 12

Global initiative for chronic obstructive lung disease (GOLD). 2015. COPD, INC.


Anticholinergics

• MOA: Blocks acetylcholine from binding muscarinic receptors to promote bronchodilation

• Adverse effects: dry mouth and bitter metallic taste• Avoid combination of short and long-acting anticholinergics

therapy

Generic Brand Formulations DOA (hours)

Short acting ipratropium Atrovent HFA Inhaler, Neb 6-8

Long actingtiotropium (R) Spiriva Inhaler 24

aclidinium (NF) Tudorza Inhaler 12


Inhaled Corticosteroid

• MOA: anti-inflammatory and relieves muscle spasm

• Adverse effects: oral candidiasis and hoarse voice

Generic Brand Formulations

beclomethasone (NF) QVAR Inhaler, Neb

budesonide (NF) Pulmicort Inhaler, Neb

fluticasone (NF) Flovent Inhaler


Phosphodiesterase-4 Inhibitors

• MOA: Anti-inflammatory

• Adverse effects: nausea, reduce appetite, headache, sleep disturbance and abdominal pain

• Criteria for Use – Requires a Non-Formulary consult

Generic Brand Formulation DOA (hours)

roflumilast (NF) Daliresp Oral pill 24


Methylxanthines (Theophylline)

• MOA: non-selective phosphodiesterase inhibitor to promote bronchodilation

• Therapeutic range for adults: 5-15 mcg/mL– Dose adjustments based on drug levels

• Adverse effects: arrhythmias, convulsion, insomnia, headaches

• Less effective and less well tolerated

• Not recommended


Combination Products

Generic Brand Formulation

Short acting beta 2-agonist + short acting anticholinergic albuterol + ipratropium Combivent Inhaler

Long acting beta 2-agonist + inhaled corticosteroid formoterol + budesonide (R) Symbicort Inhaler

formoterol + mometasone (NF) Dulera Inhaler

salmeterol + fluticasone (NF) Advair Inhaler


COPD Management

VETERANS HEALTH ADMINISTRATION

Management- Group A

• Low risk, less symptoms

1st line Alternative Other SA anticholinergic PRN SA Beta 2-agonist + SA

anticholinergicTheophylline

SA beta 2-agonist PRN LA anticholinergic

LA beta 2-agonist

SA: Short actingLA: long acting


Management- Group B

• Low risk, more symptoms

1st line Alternative Other LA anticholinergic LA anticholinergic + LA beta 2-agonist SA anticholinergic

And/ORSA beta 2-agonist

LA beta 2-agonist Theophylline

SA: Short actingLA: long acting


Management- Group C

• High risk, less symptoms

SA: Short acting LA: Long actingICS: Inhaled corticosteroid PDE-4 : Phosphodiesterase-4

1st line Alternative Others

ICS + LA anticholinergic

LA anticholinergic + LA beta 2-agonist SA anticholinergic And/OR

SA beta 2-agonist

ICA + LA beta agonist LA anticholinergic + PDE-4 Inhibitor Theophylline

LA beta 2-agonist + PDE-4 Inhibitor


Management- Group D

• High risk, more symptoms1st line Alternative Other

ICS + LA anticholinergic + LA beta 2-agonist

ICS + LA beta 2-agonist + PDE-4 inhibitor

SA anticholinergic And/OR

SA beta 2-agonist

LA anticholinergic + LA beta 2-agonist

Theophylline

LA anticholinergic + PDE-4 inhibitor

SA: Short acting LA: Long actingICS: Inhaled corticosteroid PDE-4 : Phosphodiesterase-4

Administration Technique and Counseling Pearls for COPD Inhalers

39


Background

At least 50% of patients who are prescribed inhalers may be using them incorrectly

Health care providers may have a knowledge gap when it comes to the correct use of different

inhaler devices

Suboptimal control of COPD

Pharmacist’s Letter 2014; 30(2):300206

=

&/or


Various Devices

• Metered-dose inhalers (MDI)–May require priming/shaking prior to use–Require good hand-breath coordination

• Dry-powder inhalers (DPIs)–Breath-activated

• Soft-mist inhalers



Metered-Dose Inhalers (MDIs)

Images: Google Search “metered-dose inhalers”


Available MDI Agents

• Short acting beta-2 agonists– albuterol 90 mcg

• Dosing: 1-2 inhalations QID and/or PRN

– levalbuterol 45mcg (NF)• Dosing: 1-2 inhalations QID and/or PRN

• Short acting anticholinergic– ipratropium 21 mcg

• Dosing: 1-2 inhalations QID and/or PRN

• Long-acting beta 2 agonist/corticosteroid– budesonide/formoterol 160/4.5 mcg (R)

• Dosing: 2 inhalations BID

Pharmacist’s Letter 2014; 30(2):300206Pharmacist’s Letter 2014; 30(10):3010112014 VA/DoD COPD Clinical Practice GuidelinesQID = Four times daily; PRN = as needed; BID = twice daily


MDI Agents: Short Acting Bronchodilators

Generic Brand Shake before use Priming Dose Counter

albuterol

ProAir HFA Yes Before 1st useNot used >14 days 3 sprays Yes

Proventil HFA Yes Before 1st useNot used >14 days 4 sprays No

Ventolin HFA(NF) Yes

Before 1st useNot used for >14 days

Inhaler dropped4 sprays Yes

levalbuterol (NF) Xopenex HFA Yes Before 1st use

Not used for >3 days 4 sprays Yes

ipratropium Atrovent HFA No Before 1st useNot used >3 days 2 sprays Yes

Pharmacist’s Letter 2014; 30(2):300206Pharmacist’s Letter 2014; 30(10):301011

Formulary NF = Non-formulary

Clinical pearls: -Beyond Use Date (BUD) = manufacturer’s expiration date on the packaging -Require at least weekly cleaning of device


MDI Agents: Long Acting Bronchodilators


budesonide/formoterol

(R)Symbicort Yes


Inhaler dropped2 sprays Yes

Clinical pearls: -After use of the inhaler, patient should rinse mouth with water and spit out solution-BUD = 3 months after removal from foil pouch



MDI Agents: General Steps for Use

• Remove cap• Look inside the mouthpiece for foreign objects• Shake the inhaler well, if necessary• Breathe out fully through the mouth, away from the inhaler

• Press the canister down while inhaling deeply and slowly through the mouth

• Hold breath for as long as comfortably possible (~10 seconds)• Breathe out slowly• Wait 30-60 seconds before repeating

Spacer/no spacer


Open/closed mouth


MDI: General Steps for Use (Without a Spacer)

CLOSED MOUTH• Remove cap• Check the mouthpiece for foreign objects• Shake the inhaler, if necessary• Breathe out fully through the mouth, away from the inhaler• Place the mouthpiece in mouth and tighten lips• Press the canister down while inhaling deeply and slowly through the

mouth• Remove inhaler from the mouth• Hold breath for as long as comfortably possible (~10 seconds)• Breathe out slowly• Wait 30-60 seconds before repeating

Pharmacist’s Letter 2014; 30(2):300206 Image: Google search “meter dose inhaler”


MDI: General Steps for Use (Without a Spacer)

OPEN MOUTH• Remove cap• Check the mouthpiece for foreign objects• Shake the inhaler, if necessary• Breathe out fully through the mouth, away from the inhaler• Place the inhaler two fingers’ width away from the lips• With mouth open and tongue flat, tilt the mouthpiece of the device toward the

upper back of the mouth• Press the canister down while inhaling deeply and slowly through the mouth• Move the mouthpiece away from the mouth• Hold breath for as long as comfortably possible (~10 seconds)• Breathe out slowly• Wait 30-60 seconds before repeating

Pharmacist’s Letter 2014; 30(2):300206 Image: Google search “meter dose inhalers”


MDI: General Steps for Use (With a Spacer)

• Remove cap• Look inside the mouthpiece for foreign objects• Shake the inhaler well, if necessary• Attach the spacer and the inhaler together, with the inhaler’s canister in a

vertical position• Breathe out fully through the mouth, away from the inhaler• Put the mouthpiece of the spacer between the teeth and tighten lips

around• Press the canister down and inhale deeply and slowly through the mouth• Hold breath for as long as comfortably possible (~10 seconds)• Breathe out slowly• Wait 30-60 seconds before repeating

Pharmacist’s Letter 2014; 30(2):300206 Image: Google search “meter dose inhalers”


Dry-Powder Inhalers (DPIs)

• Diskus• Ellipta• Aerolizer• Flexhaler• Diskhaler

• HandiHaler• Neohaler• Podhaler• Pressair• Twisthaler

Pharmacist’s Letter 2014; 30(2):300206Images: Google search “dry powder inhalers”


DPIs: Diskus Agents

• Long acting beta-2 agonist/corticosteroid– fluticasone/salmeterol 250/50 mcg (NF)• 1 inhalation Q12h

• Long-acting beta-2 agonists– salmeterol 50 mcg (NF)• 1 inhalation Q12h



DPIs: Diskus Agents

Generic Brand Shake before use Priming Dose Counterfluticasone/salmeterol

(NF)Advair Diskus No No Yes

Clinical pearls:-Rinse mouth after inhaler use-BUD = 1 month after removal from foil pouch or when dose counter reads “0”-No cleaning required of device

salmeterol(NF) Serevent Diskus No No Yes

Clinical pearl:-BUD = 6 weeks after removal from foil pouch or when dose counter reads “0”-No cleaning required of device



DPIs: DiskusGeneral Steps for use

• Open inhaler using the thumb grip• Hold inhaler flat & level, slide lever from left to right until it

clicks• Breathe out fully through the mouth, away from the inhaler• Put the mouthpiece in the mouth and tighten the lips around it• Inhale quickly and deeply through the mouth• Remove the device from the mouth• Hold the breath as long as comfortably possible (~10 seconds)• Breathe out slowly• Use the thumb grip to close the inhaler



DPIs: Aerolizer Agent

• Long-acting beta-2 agonist (LABA)– formoterol 12mcg (R)

• 1 inhalation twice daily


DPIs: Aerolizer Agent


formoterol (R) Foradil Aerolizer No No Yes

Clinical pearls:-Do not swallow capsules-BUD = 4 months from date of dispensing-No cleaning required of device


DPIs: Aerolizer AgentGeneral Steps for Use

• Remove inhaler cover• Hold the base of the inhaler and twist the mouthpiece in the direction of the arrow to open• Remove one capsule from its foil blister• Place capsule in the capsule chamber in the base of the inhaler• Twist the mouthpiece back to close• Hold the inhaler upright and press both buttons on the sides one time, at the same time, then

release them• Breathe out fully through the mouth, away from the inhaler• Tilt head back slightly• Hold inhaler horizontally with the buttons on the sides and place between the lips• Breathe in quickly and deeply through the mouth• Remove the inhaler from the mouth• Hold breath for as long as comfortably possible (~10 seconds), then breathe out slowly• Open the chamber to see if any powder remains in the capsule

– If yes, close the chamber and repeat the steps in bold• Open the mouthpiece, remove the used capsule and discard it• Replace inhaler cover


DPIs: HandiHaler Agents

• Long acting Anticholinergic (LAAC)– tiotropium 18 mcg (R)• 1 capsule daily



Dry-Powder Inhaler (DPI): HandiHaler Agent



tiotropium (R) Spiriva HandiHaler No No No

Clinical Pearls:-Do NOT swallow capsule-Clean after each use

Empty the remains of the capsule from the inhaler into the trash; turn the inhaler upside down and tap it firmly yet gently to remove any residue

-Clean as neededOpen the base and rinse the inhaler with warm running water; allow 24 hours to air dry

-BUD = manufacturer’s expiration date on the packaging


Dry-Powder Inhaler (DPI): HandiHalerGeneral Steps for Use

• Remove the inhaler cap by pressing the piercing button• Pull the lid away from the inhaler to expose the mouthpiece• Expose the center chamber by pulling the mouthpiece up and away from its base• Place one capsule (removed from foil blister) in the center chamber of the inhaler• Close the mouthpiece until it clicks• Continue to hold the inhaler with the mouthpiece pointed up• Press the button on the side once, then release it• Breathe out fully through the mouth, away from the inhaler• Place the inhaler in a horizontal position and place the mouthpiece in the mouth

tightening the lips around it• Breathe in deeply through the mouth• Hold the breath for a few seconds• Remove the mouth piece from the mouth• Repeat the steps in bold a second time• Open the mouthpiece, remove the used capsule and discard it• Close the mouthpiece and cap



Soft-Mist Inhalers

Image: Google search “soft-mist inhalers”


Soft-Mist Inhaler Agents

• Short acting beta-2 agonist/anticholinergic– ipratropium/albuterol 20/100 mcg• 1 inhalation QID

*Max 6 inhalations/day*• Long acting anticholinergic– tiotropium 2.5mcg (R)• 2 inhalations once daily

*Max 2 inhalations/day*

Pharmacist’s Letter 2014; 30(2):300206Package Insert: Combivent Respimat Inhaler.


Soft-Mist Inhaler Agents

Generic Brand Shake before use Priming Dose

Counter

albuterol/ipratropium

CombiventRespimat No


Spray inhaler into the air until a visible spray is seen, then spray 3

more timesNo

Not used for >3 days 1 spray

tiotropium(R)

Spiriva Respimat*Currently not

available at the VA*

No


Spray inhaler into the air until a visible spray is seen, then spray 3

more times No

Not used for >3 days 1 spray

Pharmacist’s Letter 2014; 30(2):300206Package Insert: Combivent Respimat Inhaler

Clinical pearls:-Clean weekly (wipe mouthpiece inside/out with damp tissue)-BUD = 3 months after assembly of device


Soft-Mist Inhaler: Assembly

• Before inital use

Package Insert: Combivent Respimat


Soft-Mist Inhaler: Assembly

Package Insert: Combivent Respimat


Soft-Mist Inhaler: Respimat General Steps for Use “TOP”

Hold inhaler uprightTurn the base in the direction of the arrows until it clicks

Flip the cap until it snaps openBreathe out fully through the mouth, away from the inhaler

Put the mouthpiece in the mouth and tighten the lips around the end without covering the air vents

Press the dose release button and inhale deeply and slowly through the mouth

Hold the breath as long as comfortably possible (~10 seconds)

Pharmacist’s Letter 2014; 30(2):300206Package Insert: Combivent


Quick Reference: Available COPD Inhalers

Drug Delivery Strength Dosing FormularySABAs

albuterollevalbuterol

MDIMDI

90 mcg45 mcg

1-2 inh Q4-6h PRN FormularyNon-formulary

SAMAsipratropium MDI 21 mcg 1-2 inh Q6h Formulary

SAMA/SABAipratropium/albuterol SMI 20/100 mcg 1 inh QID Formulary

LABAsformoterolsalmeterol

DPI (capsule)DPI

12 mcg50 mcg 1 inh BID

RestrictedNon-formulary

LAMAstiotropium

DPI (capsule)SMI

18 mcg2.5 mcg

1 inh (DPI) daily2 inh (SMI) daily

RestrictedComing soon

ICS/LABAsbudesonide/formoterolfluticasone/salmeterol

MDI

DPI

160/4.5 mcg

250/50 mcg

2 inh BID

1 inh BID

Restricted

Non-formulary

2014 VA/DoD COPD Clinical Practice Guidelines.


Self-Assessment

• Break into groups and demonstrate proper inhaler administration technique with each of the various delivery devices.

Smoking Cessation and Chronic Obstructive Pulmonary Disease (COPD) Management

Stephanie Cox, PharmD – [email protected] Lee, PharmD – [email protected] Williams, PharmD – [email protected]

May 29, 2015

smoking cessation and chronic obstructive pulmonary disease (copd) management stephanie cox, pharmd,...

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