CPE COPD 2013: An update on treatment and newly approved medications for pharmacists Katie Campoli Meyer Katie Campoli Meyer, PharmD, is Clinical Abstract Pharmacist, Lourdes Specialty Hospital of Southern New Jersey, Willingboro. Objective: To educate pharmacists about the Global Strategy for the Diagnosis, Correspondence: Katie Meyer, PharmD, Lourdes Specialty Hospital of Southern New Management, and Prevention of Chronic Obstructive Pulmonary Disease (GOLD) Jersey, 218 A Sunset Rd., Willingboro, NJ guidelines for treatment of chronic obstructive pulmonary disease (COPD), newly 08046. E-mail: [email protected] approved medications, and recent developments since the guidelines were pub- Reviewer: Dennis Williams, PharmD, BCPS, lished. AE-C, Associate Professor, School of Phar- Summary: The evidence-based GOLD guidelines provide recommendations macy, University of North Carolina, Chapel Hill for clinicians managing patients with COPD. These guidelines were revised most Published concurrently in Pharmacy Today recently in 2013. Three new medications (indacaterol maleate, aclidinium bromide, and the Journal of the American Pharma- cists Association (available online at www. and fluticasone furoate/vilanterol) have been approved in the previous 2 years. japha.org). Adding to the armamentarium of medications for treating COPD is useful. Studies also have been conducted to determine which inhaled agents are preferred for use when long-acting bronchodilators are needed as mono- and combination therapy. In addition, 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors and macrolides are being studied for use in COPD. An extensive COPD pipeline con- sists of many oral and inhaled medications, including olodaterol and glycopyrro- nium maleate, which are in Phase III clinical trials. Medication adherence is a very important piece of COPD management. Pharmacists play an integral role in drug selection and patient education to ensure the best possible outcomes. Conclusion: The GOLD guidelines represent the standard of care for COPD management. New drug approvals and recent research may affect practitioner Learning objectives choices in managing the disease. Pharmacists can improve medication adherence ■ Discuss appropriate medication man- and selection in order to maximize therapeutic effectiveness and ensure that pa- agement of stable chronic obstructive pulmonary disease (COPD) based on tients are using inhalation delivery devices optimally. the 2013 revised Global Strategy for the Keywords: Chronic obstructive pulmonary disease, GOLD guidelines, inda- Diagnosis, Management, and Preven- caterol maleate, aclidinium bromide, fluticasone furoate/vilanterol, adherence tion of Chronic Obstructive Pulmonary (medication). Disease guidelines. Pharmacy Today. 2013(Nov);19(11):53–64. ■ Describe the mechanism of action, rec- ommended dose, major adverse effects, drug interactions, contraindications, and place in therapy for indacaterol Accreditation information maleate, aclidinium bromide, and fluti- Provider: American Pharmacists Association ACPE number: 0202-0000-13-225-H01-P casone furoate/vilanterol. Target audience: Pharmacists CPE credit: 2 hours (0.2 CEUs) ■ Compare olodaterol and glycopyrro- Release date: November 1, 2013 Fee: There is no fee associated with this activity nium maleate, which are medications in Expiration date: November 1, 2016 for members of the American Pharmacists As- the COPD pipeline. Learning level: 2 sociation. There is a $15 fee for nonmembers. ■ Discuss recent developments in the treatment of COPD, including choice among inhaled agents, 3-hydroxy- The American Pharmacists Association is accredited by the Accreditation Council 3-methylglutaryl-coenzyme A for Pharmacy Education as a provider of continuing pharmacy education (CPE). The reductase reductase inhibitors, and ACPE Universal Activity Number assigned to this activity by the accredited provider is macrolides. 0202-0000-13-225-H01-P. ■ Recognize the importance of medica- Disclosure: Dr. Williams declares that his spouse/partner is an employee and a stock/sharehold- tion adherence, barriers to adherence, er of GlaxoSmithKline. Dr. Meyer and APhA’s education staff declare no conflicts of interest or and the pharmacist’s role in improving financial interests in any product or service mentioned in this activity, including grants, employ- patient adherence to COPD treatment ment, gifts, stock holdings, and honoraria. For complete staff disclosures, please see the APhA regimens. Accreditation Information section at www.pharmacist.com/education. www.pharmacytoday.org NOVEMBER 2013 • PharmacyToday 53 CPE COPD UPDATE Case study tients who present with these symptoms plus have a history Chief complaint. J.P. is a 72-year-old man who presents to his physi- of exposure to irritants (e.g., tobacco smoke, occupational cian’s office with worsening symptoms of shortness of breath and chemicals) or a family history of COPD. Postbronchodila- decreased oxygen saturation of 80%. The patient was placed in a bed, tor spirometry confirms a suspected diagnosis if the pa- put on oxygen via nasal cannula, and given a nebulizer treatment and tient’s forced expiratory volume in 1 second (FEV ) divided an intravenous steroid injection. The patient’s oxygen saturation (O ) 1 2 2 improved to 96% posttreatment. by forced vital capacity (FVC) is less than 70%. The Global History of current illness. The patient has a past medical history Strategy for the Diagnosis, Management, and Prevention of noteworthy for chronic obstructive pulmonary disease (COPD) second- Chronic Obstructive Pulmonary Disease (GOLD) guidelines ary to a long-term smoking history. The patient quit smoking 5 years classify COPD severity in patients into four grades upon ago when he was diagnosed with COPD. He has had to use his albuterol diagnosis (Table 1). Patients are further classified into four inhaler much more frequently during the previous 3 days (at least four groups that incorporate patient-specific symptoms based to five times per day). He was given a steroid taper about a month ago for a COPD exacerbation. He also has hypertension, dyslipidemia, on exacerbation rate and validated questionnaires regard- overactive bladder, and insulin-dependent diabetes. ing symptom severity and frequency (Table 2). The patient Allergies. The patient is allergic to clarithromycin (rash). group classification aides in determining a preferred treat- Current home medications. Insulin glargine 50 units s.c. twice ment regimen. daily, atenolol 50 mg orally daily, aspirin 81 mg orally daily, rosuvas- tatin 10 mg orally daily, lisinopril 5 mg orally daily, formoterol 12 µg 1. Based on J.P.’s history, in which GOLD group would he be clas- one inhalation twice daily, furosemide 40 mg orally daily, solifenacin sified? 10 mg orally daily, and albuterol 90 µg one inhalation every 4 hours as a. A needed for wheezing. b. B Social history. The patient lives at home with his wife. He has a c. C smoking history of 50 pack-years but stopped smoking 5 years ago. d. D J.P. also worked in a steel mill. He has no history of alcohol or any other recreational drugs. Treatment of stable COPD Vital signs. Blood pressure 171/74 mm Hg, heart rate 109 bpm, The goals of pharmacologic treatment are to reduce symp- respiratory rate 30 breaths per minute, O saturation 80% recovered 2 toms, reduce the frequency and severity of exacerbations, to 96%, temperature 98.6°F, and forced expiratory volume in 1 second and improve exercise tolerance and health status.2 All pa- (FEV ) 40%. 1 tients who smoke should be provided help quitting in order to improve the natural history of COPD. Smoking cessation Chronic obstructive pulmonary disease (COPD) affects programs with nicotine replacement therapy and/or phar- an estimated 14.8 million individuals worldwide, with an macologic therapy should be initiated as soon as possible in estimated 12 million cases currently undiagnosed.1 COPD is order to delay the progression of COPD.2 All patients with a leading cause of morbidity and mortality worldwide, re- COPD also should be offered the pneumococcal polysaccha- sulting in an increasing social and economic burden.2 It is ride vaccine. An annual influenza vaccine is indicated for all the third leading cause of death in the United States.3 COPD patients, independent of age, to reduce their risk of complica- costs an estimated $29.5 billion directly and $20.4 billion in tions from infection.2,6 indirect costs annually.2 COPD is most prevalent in men, The GOLD guidelines for pharmacological management smokers, and individuals older than 40 years.4 recommend a stepwise approach to treatment based on pa- COPD is characterized by progressive inflammation that tient classification. All patients should be prescribed a res- causes modification and narrowing of pulmonary airways, cue inhaler (short-acting beta agonist or beta agonist/anti- leading to development of chronic airflow limitation. Dam- cholinergic combination). Treatment of patients in group A age to the parenchyma of the lungs also occurs. Chronic consists of a short-acting bronchodilator used only as needed inflammation causes changes in small airways and lung for symptomatic relief. These patients have few symptoms parenchyma that lead to decreased lung recoil and an in- and a low exacerbation risk. Long-acting bronchodilators are ability of the airways to remain open during expiration.2 recommended as the agent of choice for patients in group The inflammatory process is initiated by macrophages and