David Young, Pharm.D. There are no relationships to disclose related to this presentation. David Young, Pharm.D. Professor of Pharmacotherapy L.S. Skaggs Pharmacy Institute Rm 4916 581-8510 [email protected] ¡ Differentiate between the stages of asthma ¡ Define asthma and copd and copd based on current guidelines ¡ Identify which medications are classified as ¡ Recognize the current therapeutic options to long-term control and quick-relief treat patients with asthma and copd medications ¡ Identify an appropriate stepwise approach to ¡ Identify potential adverse effects from long- treat patients with asthma and copd term control and quick-relief medications ¡ Recognize the importance of correct inhaler ¡ Recognize the importance of correct inhaler technique technique ¡ Affects 8% of US population § 25.7 million in 2010 § 1:11 children § 1:12 adults § 8.9 million office visits in 2009 § 1.9 million emergency room visits in 2009 § 479,00 hospitalizations in 2009 § 14.2 million missed work in 2006 David Young, Pharm.D. Professor of Pharmacotherapy L.S. Skaggs Pharmacy Institute Rm 4916 581-8510 [email protected] http://www.cdc.gov/asthma/impacts_nation/AsthmaFactSheet.pdf accessed 5/18 1 ¡ High cost Asthma is a chronic inflammatory disorder of § $56 billion/year the airways where the obstruction is: § $3,300/person/year a) reversible ¡ Mortality b) irreversible § 3388 deaths in the US in 2009 c) untreatable d) permanent http://www.cdc.gov/asthma/impacts_nation/AsthmaFactSheet.pdf accessed 12/17 ¡ “Asthma is a CHRONIC INFLAMMATORY disorder of the airways in which many cells and cellular elements play a role: in particular, mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells. In susceptible individuals, this INFLAMMATION is associated with recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread, but variable airflow obstruction within the lung that is often REVERSIBLE either spontaneously or with treatment. ” EPR 3, 2007 histamine, leukotrienes, Bronchospasm mast cell é Vascular permeability prostaglandins, bradykinin é Mucus production IL-5 IgE Cytokines VCAM-1 (TLSP) eosinophils macrophage Antigen IL-4 B lymphocyte IL-4 IL-13 IL-3, IL-5, GM-CSF T lymphocyte IL-8 neutrophils Chemokines Inflammation: LTB-4 1. Acute sx 2. Subacute sx 3. Chronic sx 4. Airway Adapted from EPR 2, 1997 remodeling 2 ¡ Etiology / Triggers ¡ Reduce impairment ¡ Reduce risk § Prevent chronic and § Prevent recurrent § Allergens troublesome symptoms exacerbations of asthma § Require infrequent use and minimize the need for § Exercise (<2 day/week) of inhaled emergency department SABA (ED) visits or § Infections § Maintain (near) normal hospitalizations § Occupational pulmonary function § Prevent progressive loss § Maintain normal activity of lung function; for § Environmental levels (including exercise) children, prevent reduced lung growth § Meet patients’ and § Drugs / Foods families’ expectations of § Provide optimal satisfaction with asthma pharmacotherapy with care minimal or no adverse effects EPR 3, 2007 EPR 3, 2007 AB is at your clinic with a 4-week history of coughing and shortness of breath (SOB) three times/week that awakens him at night 1 time/week. He also reports that he feels that his asthma has impacted his ability to exercise. His current medications include: albuterol prn, lisinopril/hctz, atorvastatin, metformin. Based on the above case, how would you classify AB’s asthma control according to the GINA guidelines? a) Controlled b) Partially controlled c) Uncontrolled d) Persistent A. Symptom control 1. Well- Partly Uncontrolled Asthma control - two domains In the past 4 weeks, has the patient had: controlled controlled § Assess symptom CONTROL over the last 4 weeks • Daytime asthma symptoms more § Assess RISK FACTORS for poor outcomes, including low lung than twice a week? function Yesq Noq 2. Treatment issues • Any night waking due to asthma? § Check inhaler technique and adherence § Ask about side-effects Yesq Noq None of 1-2 of 3-4 of • Reliever needed for symptoms* these these these § Does the patient have a written asthma action plan? more than twice a week? § What are the patient’s attitudes and goals for their asthma? Yesq Noq 3. Comorbidities • Any activity limitation due to asthma? § Think of rhinosinusitis, GERD, obesity, obstructive sleep apnea, depression, anxiety Yesq Noq § These may contribute to symptoms and poor quality of life B. Risk factors for poor asthma outcomes • Assess risk factors at diagnosis and periodically • Measure FEV at start of treatment, after 3 to 6 months of treatment to record the patient’s GINA, 2017 1 Adapted from GINA, 2017 personal best, then periodically for ongoing risk assessment GINA 2017, Box 2-1 GINA 2017,ASSESS PATIENT’S RISKS FOR: Box 2-1 • Exacerbations • Fixed airflow limitation • Medication side-effects 3 ¡ Risk factors for exacerbations include: How? § • Ever intubated for asthma Asthma severity is assessed retrospectively from the level of • Uncontrolled asthma symptoms treatment required to control symptoms and exacerbations • Having ≥1 exacerbation in last 12 months ¡ When? • Low FEV1 (measure lung function at start of treatment, at 3-6 months to assess personal best, and § Assess asthma severity after patient has been on controller treatment periodically thereafter) for several months • Incorrect inhaler technique and/or poor adherence • Smoking § Severity is not static – it may change over months or years, or as • Elevated FeNO in adults with allergic asthma different treatments become available • Obesity, pregnancy, blood eosinophilia ¡ Categories of asthma severity Risk factors for fixed airflow limitation include: § Mild asthma: well-controlled with Steps 1 or 2 (as-needed SABA or low • No ICS treatment, smoking, occupational exposure, mucus hypersecretion, blood eosinophilia dose ICS) Risk factors for medication side-effects include: § Moderate asthma: well-controlled with Step 3 (low-dose ICS/LABA) • Frequent oral steroids, high dose/potent ICS, P450 inhibitors § Severe asthma: requires Step 4/5 (moderate or high dose ICS/LABA ± add-on), or remains uncontrolled despite this treatment GINA, 2017 Adapted from GINA, 2017 GINA 2017, Box 2-1 GINA 2017 ¡ Severity based on treatment required to Which of the following asthma medications is a control symptoms and exacerbations reliever? ¡ Follow up regularly to assess effectiveness of a) fluticasone therapy b) budesonide ¡ Step up / down based on response to therapy c) montelukast d) levalbuterol ¡ Short-acting beta-2 agonist (SABA) § Albuterol ▪ MDI (Albuterol HFA, Proventil HFA, Ventolin HFA, ProAir HFA) ▪ DPI (ProAir RespiClick) ▪ Nebulized ▪ Oral tablets & syrup § Levalbuterol ▪ MDI (Xopenex HFA) ▪ Nebulized (Xopenex) § Epinephrine (Asthmanefrine) ▪ Approved >4yrs ▪ 0.5ml (11.25mg epinephrine) via EZ Breathe Atomizer 1-3 inhalations every 3 hours prn (maximum 12 inhalations/24hr) ▪ Seek medical help if no relief in 20 minutes ¡ Short-acting muscarinic antagonist (SAMA) § MDI (Atrovent HFA) § Nebulized (Ipratropium) 4 ¡ Albuterol, Levalbuterol ¡ Clinical Use ¡ Ipratropium § Relief of acute symptoms / attacks ¡ Clinical use: § Prevention of exercise-induced bronchospasm (EIB) § Off label use for asthma in combination with § Frequency of use = good monitoring tool SABA for acute exacerbations (Combivent, ▪ SABA <1 MDI/month ¡ Adverse effects Duoneb) § Anxiety, insomnia, tremor, and palpitations § DOES NOT PRECLUDE THE USE OF ▪ MDI<Nebulizer<Oral<Parenteral CORTICOSTEROIDS ¡ Any patient using a short acting beta-2 agonist on regular ¡ Adverse effects basis without an anti-inflammatory should be referred for reevaluation § Anticholinergic (dry mouth) GINA, 2017 GINA, 2017 Lexi-Drugs Online. Hudson, Ohio: Lexi-Comp, Inc.; January 2018 Lexi-Drugs Online. Hudson, Ohio: Lexi-Comp, Inc.; January 2018 ¡ Albuterol/Ipratropium ¡ Inhaled corticosteroid ¡ ICS + LABA (Long-acting (ICS) beta-2 agonist) § § Combivent Respimat (100mcg/20mcg) § Beclomethasone (Qvar; Qvar Fluticasone proprionate/ Redihaler) Salmeterol (Advair diskus, ▪ 1 inhalation QID (max 6/24hr) Advair HFA, Airduo) § Budesonide (Pulmicort Flexhaler, Pulmicort Respules) § Budesonide/Formoterol § Duoneb (2.5mg/0.5mg) (Symbicort HFA) § Ciclesonide (Alvesco) ▪ 3ml neb QID § Mometasone/Formoterol § Fluticasone (Flovent HFA, (Dulera) Flovent Diskus, Arnuity Ellipta) ¡ Combination more effective than individual § Fluticasone furorate/Vilanterol § Flunisolide (Aerospan) (Breo Ellipta) agents for acute asthma exacerbation § Mometasone (Asmanex ¡ Long-acting muscarinic Twisthaler, Asmanex HFA) agonist (LAMA) § Tiotropium EPR 3, 2007 ¡ Theophylline ¡ Clinical use: ¡ Leukotriene modifiers § Inhaled route preferred for chronic use § Start controller treatment early § Montelukast ▪ For best outcomes, initiate controller treatment as early as possible after § Zafirlukast making the diagnosis of asthma § Indications for regular low-dose ICS - any of: § Zileuton ▪ Asthma symptoms more than twice a month ¡ Cromolyn ▪ Waking due to asthma more than once a month ¡ Biologics ▪ Any asthma symptoms plus any risk factors for exacerbations § Omalizumab ¡ Adverse effects § Oropharyngeal candidiasis § Mepolizumab § Dysphonia § Reslizumab § Cough GINA, 2017 Lexi-Drugs Online. Hudson, Ohio: Lexi-Comp, Inc.; January 2018 5 Inhaled steroid Total daily dose (mcg) Low Medium High Beclometasone 200–500 >500–1000 >1000 ¡ Salmeterol (Serevent diskus): dipropionate (CFC) Beclometasone