Catch Your Breath Updates in Asthma and COPD Pharmacotherapy

CATCH YOUR BREATH UPDATES IN ASTHMA AND COPD PHARMACOTHERAPY Hanna Raber, PharmD, BCPS, BCACP Assistant Professor (Clinical), University of Utah College of Pharmacy Objectives ■ Describe updates to the GINA/GOLD guidelines for asthma/COPD management ■ Compare and contrast dry powder, metered dose, and soft mist inhaler types ■ Discuss new inhaler products recently approved by the FDA ■ Recommend medication access options for patients who need assistance affording inhalers GUIDELINE UPDATES Patient Case ■ A 19-year-old female presents to your family medicine clinic to establish care and f/u on her asthma diagnosis. The patient reports she was diagnosed with asthma several years ago and has since used albuterol as needed to control her symptoms. ■ Patient reports she typically uses her inhaler about 2x monthly to control her symptoms. She is currently out of her medication and needs a new prescription. What pharmacotherapy treatment would you consider for this patient? Asthma Guideline Updates – GINA 2019 Major Updates 2019 SABA-only no Updated Step Add-On longer Therapy Tiotropium recommended Global Initiative for Asthma (GINA) 2019. Global Strategy for Asthma Management and Prevention. Mild Asthma Moderate Severe Asthma Asthma Step 1 Step 2 Step 3 Step 4 Step 5 Controller Preferred PRN low Low dose ICS Low dose ICS- Medium dose High dose Options dose ICS- LABA ICS-LABA ICS-LABA + formoterol Refer for add- on treatment Alternative - Low dose -LTRA -Med dose ICS -High dose ICS -Low dose Options ICS taken -Low dose ICS -Low dose ICS -Add OCS whenever taken whenever +LTRA tiotropium SABA is SABA is taken -Add LTRA taken Reliever Preferred PRN low dose ICS-formoterol Options Alternative As-needed SABA Options Global Initiative for Asthma (GINA) 2019. Global Strategy for Asthma Management and Prevention. Mild Asthma Moderate Severe Asthma Asthma Step 1 Step 2 Step 3 Step 4 Step 5 Controller Preferred PRN low Low dose ICS Low dose ICS- Medium dose High dose Options dose ICS- LABA ICS-LABA ICS-LABA + formoterol Refer for add- on treatment Alternative - Low dose -LTRA -Med dose ICS -High dose ICS -Low dose Options ICS taken -Low dose ICS -Low dose ICS -Add OCS whenever taken whenever +LTRA tiotropium SABA is SABA is taken -Add LTRA taken Reliever Preferred PRN low dose ICS-formoterol Options Alternative As-needed SABA Options Global Initiative for Asthma (GINA) 2019. Global Strategy for Asthma Management and Prevention. Asthma Guideline Updates – GINA 2019 ■ Step 1 Preferred Controller: PRN low dose ICS-formoterol – “SABA-only treatment no longer recommended” – For patients with symptoms < 2x/monthly and no risk factors ■ Concerns – Insurance coverage – Limited to budesonide-formoterol Global Initiative for Asthma (GINA) 2019. Global Strategy for Asthma Management and Prevention. Mild Asthma Moderate Severe Asthma Asthma Step 1 Step 2 Step 3 Step 4 Step 5 Controller Preferred PRN low Low dose ICS Low dose ICS- Medium dose High dose Options dose ICS- LABA ICS-LABA ICS-LABA + formoterol Refer for add- on treatment Alternative - Low dose -LTRA -Med dose ICS -High dose ICS -Low dose Options ICS taken -Low dose ICS -Low dose ICS -Add OCS whenever taken whenever +LTRA tiotropium SABA is SABA is taken -Add LTRA taken Reliever Preferred PRN low dose ICS-formoterol Options Alternative As-needed SABA Options Global Initiative for Asthma (GINA) 2019. Global Strategy for Asthma Management and Prevention. Asthma Guideline Updates – GINA 2019 ■ High dose ICS-LABA treatment limited to Step 5 – Limit use to 3-6 months – Little additional benefits from medium high dose – Increased risk of side effects Global Initiative for Asthma (GINA) 2019. Global Strategy for Asthma Management and Prevention. Mild Asthma Moderate Severe Asthma Asthma Step 1 Step 2 Step 3 Step 4 Step 5 Controller Preferred PRN low Low dose ICS Low dose ICS- Medium dose High dose Options dose ICS- LABA ICS-LABA ICS-LABA + formoterol Refer for add- on treatment Alternative - Low dose -LTRA -Med dose ICS -High dose ICS -Low dose Options ICS taken -Low dose ICS -Low dose ICS -Add OCS whenever taken whenever +LTRA tiotropium SABA is SABA is taken -Add LTRA taken Reliever Preferred PRN low dose ICS-formoterol Options Alternative As-needed SABA Options Global Initiative for Asthma (GINA) 2019. Global Strategy for Asthma Management and Prevention. Asthma Guideline Updates – GINA 2019 ■ Step 4: Tiotropium as add-on therapy – Patients aged 6 years and older – Modestly improves lung function – Modestly reduces exacerbations Global Initiative for Asthma (GINA) 2019. Global Strategy for Asthma Management and Prevention. Patient Case ■ A 67 year old Caucasian male with a PMH significant for diabetes, hypertension, gout, and tobacco use (1ppd x 20 years) presents to your family medicine clinic with a chief complaint of dyspnea and chronic cough ■ Spirometry is completed and confirms diagnosis of COPD ■ Patient has no history of exacerbations and his CAT™ assessment score is 12 What pharmacotherapy treatment would you consider for this patient? COPD Guideline Updates – GOLD 2019 Major Updates 2019 Streamlined Management Initial EOS for ICS Cycle Treatment Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: 2019 Report COPD Guideline Updates – GOLD 2019 Initial Treatment: Group D: > 2 moderate exacerbations or >1 Group C: LAMA or leading to LAMA LAMA + LABA* or *Consider if highly hospitalization symptomatic (e.g. ICS + LABA** CAT >20) **Consider if eos > 300 0 or 1 moderate Group A: exacerbations (not Group B: leading to hospital Bronchodilator admission) LABA or LAMA mMRC 0-1 CAT <10 mMRC > 2 CAT > 10 Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: 2019 Report COPD Guideline Updates – GOLD 2019 Initial Treatment: Group D: > 2 moderate exacerbations or >1 Group C: LAMA or leading to LAMA LAMA + LABA* or *Consider if highly hospitalization symptomatic (e.g. ICS + LABA** CAT >20) **Consider if eos > 300 0 or 1 moderate Group A: exacerbations (not Group B: leading to hospital Bronchodilator admission) LABA or LAMA mMRC 0-1 CAT <10 mMRC > 2 CAT > 10 Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: 2019 Report COPD Guideline Updates – GOLD 2019 ■ Consider blood eosinophil count to determine if inhaled steroids should be included – Consider inhaled steroids if eosinophils >300 cells/uL – Less benefit if eosinophils <100 cells/ Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: 2019 Report COPD Guideline Updates – GOLD 2019 Management Cycle Review Symptoms Exacerbations Adjust Assess Escalate Inhaler technique Switch inhaler device or molecules Adherence De-escalate Non-pharm approaches Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: 2019 Report COPD Guideline Updates – GOLD 2019 Follow-Up Treatment (DYSPNEA): LABA or LAMA **Consider de- escalation of ICS or ** switch if: LABA + LAMA ** LABA + ICS -Pneumonia -Lack or response -Inappropriate use -Switch inhaler device LABA + LAMA+ ICS or medication - R/O other causes of dyspnea Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: 2019 Report COPD Guideline Updates – GOLD 2019 Follow-Up Treatment (EXACERBATIONS): *Consider if eos ≥ LABA or LAMA 300 or eos ≥ 100 * and ≥ 2 moderate exacerbations/1 ** hospitalization LABA + LAMA ** LABA + ICS **Consider de- escalation of ICS or switch if: -Pneumonia LABA + LAMA+ ICS -Lack or response -Inappropriate use Roflumilast Azithromycin FEV1 <50% and chronic bronchitis In former smokers Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: 2019 Report INHALER REVIEW Inhaler review ■ Up to 80% of community patients have poor inhaler technique ■ Inhaler misuse associated with: – ↑ Risk of Hospitalizations – ↑ Emergency Room Visits – ↑ Oral Steroid Use – ↑ Antimicrobial Use ■ Many healthcare providers unable to correctly demonstrate inhaler use Global Initiative for Asthma (GINA) 2019. Global Strategy for Asthma Management and Prevention. Inhaler Review Dry Powder Metered Soft Dose Mist Inhaler Types S. P. Newman. European Respiratory Review Dec 2005, 14 (96) 102-108 Metered Dose Inhalers (MDI) ■ Examples: – Advair® HFA, QVAR Redihaler ®, Symbicort® ■ MDI Tips – Shake before use – Prime? – Inhale deeply and slowly – Spacer S. P. Newman. European Respiratory Review Dec 2005, 14 (96) 102-108 Spacers ■ For use with MDI only ■ Improves delivery – ↓ Velocity = ↓ Medication deposited in throat ■ Reduces side effects (corticosteroids) 2019 Global Initiate For Asthma Strategy for Asthma Management and Prevention Dry Powder Inhalers (DPI) ■ Examples: – Flovent Diskus ®, Arnuity Ellipta ®, Spiriva HandiHaler ® ■ DPI Tips: – Load dose – Do not shake – Do not prime – Inhale deeply and quickly S. P. Newman. European Respiratory Review Dec 2005, 14 (96) 102-108 Soft Mist Inhalers (SMI) ■ Examples: – Combivent Respimat ®, Spiriva Respimat

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