Asthma/COPD
Jonny Nguyen, PharmD Candidate 2024
Table of Content
1. Background 2. Diagnosis 3. Assessment 4. Guidelines 5. Treatment 6. Non-drug treatment 7. Key Counseling Points 8. Resources
COPD
ASTHMA
Chronic obstructive pulmonary disease (COPD) is characterizied by chronic, progressive symptoms such as
- Cough
- Dyspnea
- Sputum production
- Wheezing
due to abnormalities of the airway (bronchitis) and/or alveoli (emphysema) that causes persistent, often progressive, airflow obstruction The limitation of airflow is not fully reversible and progresses over time, leading to a gradual loss of lung function
Asthma is usually characterizied by chronic airway inflammation and bronchoconstriction, leading to expiratory airflow limitation It is defined by the history of respiratory symptoms that vary over time and intensity, such as
Symptoms and airflow limitation may resolve spontaneously or in response to medication
- Chest tightness
- Cough
- Dyspnea
- Wheezing
ASTHMA CAUSES AND RISK FACTOR
Drugs
Aspirin, NSAID, non-selective beta-blockers
Pollution
ASTHMA
Dust& Pollen
Weather
Perfume& Cosmetic
Cigarettes
COPD CAUSES AND RISK FACTOR
Genetic mutation in the SERPINA1 gene leads to an a-1 antitrypsin (AAT) deficiency. AAT provides protection from damaged caused by inflmmation in the lung
Tobacco smoking and inhalation of toxic particles and gases from household and outdoor air pollution are the main environmental exposure leading to COPD
DIAGNOSIS
Diagnosis for asthma and COPD can be confirmed with using a spirometer. Spirometry assess lung function with various test such as,
An FEV1 increase >12% post-bronchodilator is consistent with asthma diagnosis (considered 'reversible')
Key Differences of Asthma VS COPD
ASSESSMENT OF ASTHMA
Initial assessment
Assessing asthma control after initial assessment
- Daytime asthma symptoms > twice/week?
- Any nighttime awakening due to asthma?
- Short-acting beta agonists (SABA) reliver treatment used > twice/week? (Only for patient on therapy)
- Is activity limited due to asthma?
Assessed at each visit using the following four yes/no questions
Sed diam nonummy nibh euismodmagna aliquam erat volutpat"
Author Name
The number of 'YES' determines the level of asthma control:
- Well-controlled: 0 yes. Maintain current step (or step down if controlled for at least 3 months)
- Partly controlled: 1 - 2 YES. Step up 1 step
- Uncontrolled: 3 - 4 YES. Step up 1 - 2 steps and consider a short course or oral steroids
ASTHMA TREATMENT ALOGORITHM
RESCUE INHALER
MAINTENANCE INHALER
STEPS
As-needed low-dose ICS-FORMoTEROL
low-dose ICS-FORMoTEROL
High-doseICS-formoterol
--
OR
OR
SABA + Low-dose ICS (take together)
--
High-dose ICS-LABA
SABA
As-needed low-dose ICS-FORMoTEROL
--
OR
SABA
Low-dose ICS
Low-dose ics-formoterol
Low-doseICS-formoterol
OR
Low-dose ICS-LABA
SABA
ICS - inhaled corticosteroidSABA - short acting beta agonist LABA - long acting beta agonist
low-dose ICS-FORMoTEROL
Medium-doseICS-formoterol
OR
High-dose ICS-LABA
SABA
Alternative treatments for step:
- 2: LTRA, or low-dose ICS taken whenever SABA is taken
- 3: Low-dose ICS+LTRA or mewdium-dose ICS
- 4: High-dose ICS or add on tiotropium
- 5: consider adding tiotropium, opral steroid, or injectable treatments (omalizumnab, reslizumab)
ASSESSMENT OF COPD
modified British Medical Research Councel (mMRC) Scale: 0-4
COPD assessment includes the following 4 compononet:
- Degree of airflow limitation (diverse severity)
- Symptoms (mMRC, CAT)
- Risk of exacerbation
- Presence of comorbidities
COPD Assessment Test (CAT)
Severity of post-bronchodilator airlflow limitation
In patients with FEV1/FVC <0.70
ASSESSMENT OF COPD
COMORBIDITIES
- Cardiovascular disease
- Osteoporosis
- Diabetes
- Depression
- Anxiety
- Skeletal muscle dysfunction
- Respiratory infection
- Lung cancer
A COPD exacebation is an increase in respiratory symptoms that worsen over less than 14 days. If patient has 2 or more exacerbation per year, they are considered frequent exacerbators. Risk will further increase as airflow limitation worsens and hospitalization for an exacerbation is assocaited with an increase risk of death.
RISK
COPD INITIAL TREATMENT ALOGORITHM
RISK
0 or 1 moderate exacerbation (not leading to hospital admission)
CAT <10mMRC 0-1
CAT >10mMRC ≥2
≥2 moderate exacerbations or ≥1 leading to hospital admission
SYMPTOMS
COPD TREATMENT ESCALATION
Primary Problem
Switch inhaler, check for other casues
LAMA + LABA
LAMA OR LABA
DYSPNEA
COPDNot well controlled
EOS ≥100
EOS < 300
LAMA + LABS + ICS
LAMA + LABA
EOS <100
EXACERBATION(Acute worsening /flare-up)
Consider roflumilast or azithromycin
LAMA OR LABA
EOS ≥ 300
LAMA + LABA +ICS
Long-Acting Beta-2 Agonist
Salmeterol 50mcg/inhalation
- Servent Diskus
- +Fluticasone (Advair Diskus)
Side Effects: Nervousness, Tremor, Tachycardia, Palpitations, Cough, Hyperglycemia, Hypokalemia
Dosing: DPI: 1 inhalation BID
Formoterol 20mcg/2ml nebulizer soln
- MDI: +Budesonide (Symbicort)
Dosing: Nebulizer: 20mcg BID MDI: 2 inhalations BID
BOXED WARNING: LABA increase the risk of asthma-related deaths when used alone; should be using with ICS but are not adequately controlled
Short-Acting Beta-2 Agonist
Albuterol 90mcg/inhalation
- MDI: ProAir HFA, Proventolin HFA, Ventolin HFA
- DPI: ProAir Respiclick
Side Effects: Nervousness, Tremor, Tachycardia, Palpitations, Cough, Hyperglycemia, Hypokalemia
Dosing: MDI/DPI: 1-2 inhalations q4-6h prn Nebulizer: 1.25-6mg q-5h prn*PO forms are available but not recommended
Levalbuterol 45mcg/inh, nebulizer soln
Dosing: MDI: 1-2 inhalations q4-6h prn Nebulizer: 0.63-1.25mg q6-8h prn
Mechanism of action: relaxes bronchial smooth muscle by selectively binding to beta-2 receptors, leading to bronchodilation
LABA are used for maintenance inhalation only; not for acute bronchospasm
Monitoring: Number of days of SABA use, symptom frequency, peak flow, pulmonary function test, BP, HR, blood glucose, K
Warning: Caution in CVD, glaucoma, hyperthyroidism, seizures, diabets
Mechanism of action: blocks the constricting actions of acethylcholine at M3 muscarinic receptors in bronchial smooth muscle, leading to bronchodilations
Avoid spraying in the eyes; HandiHaler are DPI with capsules, do not swallow by mouth
Monitoring: S/sx at each visit, smoking status, COPD questionnatires, annual spirometry
Warning: Patient with narrow-angle glaucoma, myasthenia gravis, urinary retention, benigh prostatic hyperplasia, and bladder neck obstruction
Long-Acting Muscarinic Antagonist
Short-Acting Muscarinic Antagonist
Tiotropium
Ipratropium bromide 17mcg/inh, 0.02 nebulizer soln
- Spiriva HandiHaler (18mcg cap)
- Spiriva Respimat (2.5mcg/inh)
- Atrovent HFA
- +Albuterol (Combivent Respimat)
Dosing: DPI: inhale contents of 1 caps via Handihaler device daily (2 puff require) MDI: 2 inbhallations daily
20 mcg ipratropium + 100mcg albuterol/inhalation Nebulizer soln: 0.5 mg ipratropium + 2.5mg albuterol per 3ml
Dosing: Ipratropium: MDI: 2 inh QIDNebulizer: 0.5 mg TID-QID Combivent: MDI: 1 inh QIDnebulizer 3ml QID
Side Effects: Dry mouth, upper respiratory tract infection, cough, bitter taste
Side Effects: Dry mouth, upper respiratory tract infection, cough, bitter taste
INHALED CORTICOSTEROIDS
- Beclamethasone (QVAR RediHaler)
- Budesonide
- Pulmicort Flexhaler
- Pulmicort Repulses
- Fluticasone
- Flovent HFA
- Flovent Diskus
- Arnuity Ellipta
- 90,180 mcg/inh
- nebulizer susp
- 44, 110, 220 mcg/inh
- 50, 100, 250 mcg/inh
- 100, 200 mcg/inh
- 100, 200 mcg/inh
- 110, 220 mcg/inh
- MDI: 1-2 inhalation BID
- DPI: 1-2 inhalation daily
- MDI: 2 inhalation BID
- DPI: 1-92 inhalation BID
- DPI: 1-2 inhalation daily
- DPI: 1-4 inhalation BID
- Nebulizer: 0.25-0.5mg daily or BID in children age 1-8 years
Mechanism of action: inhibit the inflmmatory response by blocking late-phase reaction to allergens, reduce airway hyperresponsiveness and are potent and effective anti-inflammatory medication.
Rinse mouth and water and spit out after each use to prevent thrush; spacer device with MDI reduce risk
Monitoring: Use of SABA/rescue inhaler, symptom frequency, peak flow, s/sx adrenal insufficiency, s/sx of thrush, bone mineral density
Warning: High doses for prolonged period of time can cause adrenal suppression, increase risk of fractures, growth retardation (in children), and immunosuppression
CONTRAINDICATION: Primary treatment of status asthmaticus or acute episodes of asthma
LAMA/LABA
LAMA/LABA/ICS
ICS/LABA
Budesonide/FormoterolSymbicort Fluticasone/Salmeterol Advair Diskus, Advair HFA Mometasone/Formoterol Dulera Fluticasone/Vilanterol Breo Elipta
No combination LAMA/LABA product are FDA-approved for asthma
ASTHMA
Umeclidinium/Vilanterol/Fluticasone (Trelegy Elipta)
Aclidinium/Formoterol Duaklir PressairGlycopyrolate/Formoterol Bevespi Aerosphere Tiotropium/Olodaterol Stiolto Respimat Umeclidinium/Vilanterol Anoro Elipta
Budesonide/FormoterolSymbicort Fluticasone/Salmeterol Advair Diskus Mometasone/Formoterol Dulera Fluticasone/Vilanterol Breo Elipta
Umeclidinium/Vilanterol/Fluticasone (Trelegy Elipta)Glycopyrrolate/Formeterol/Budesonide (Breztri Aerosphere)
COPD
Non-Pharmacological Management: COPD
Non-Pharmacological Interventions: ASTHMA
- Cessation of smoking, environmental tobacco exposure, and vaping
- Physical activity
- Avoidance of occupational or domestic exposure to allergans or irritants
- Avoidance of medication that may make the asthma works: Aspirin and NSAID
- Healthy diet (high in fruit and vegetables)
- Allergan avoidance is not recommended as a general strategy in asthma
- Breathing exercise (useful supplement to asthma pharmacotherapy for symptoms and quality of life)
- Influenza Vaccination
Essential: Smoking cessation (can include pharmacological treatment)Pulmonary rehabilitation** Recommended: Physical activity Vaccination: Flu Pneumococcal Pertussis COVID-19 Shingles
** : pulmonary rehabilitation is recommended for patients categorized in only the B and E group during assessment
ASTHMA/COPD
Jonny Nguyen
Created on October 21, 2023
Start designing with a free template
Discover more than 1500 professional designs like these:
View
Practical Video
View
Akihabara Video
View
Essential Video
View
Video: Responsible Use of Social Media and Internet
View
Explainer Video: Keys to Effective Communication
View
Explainer Video: AI for Companies
View
Breaking news video
Explore all templates
Transcript
Asthma/COPD
Jonny Nguyen, PharmD Candidate 2024
Table of Content
1. Background 2. Diagnosis 3. Assessment 4. Guidelines 5. Treatment 6. Non-drug treatment 7. Key Counseling Points 8. Resources
COPD
ASTHMA
Chronic obstructive pulmonary disease (COPD) is characterizied by chronic, progressive symptoms such as
due to abnormalities of the airway (bronchitis) and/or alveoli (emphysema) that causes persistent, often progressive, airflow obstruction The limitation of airflow is not fully reversible and progresses over time, leading to a gradual loss of lung function
Asthma is usually characterizied by chronic airway inflammation and bronchoconstriction, leading to expiratory airflow limitation It is defined by the history of respiratory symptoms that vary over time and intensity, such as
Symptoms and airflow limitation may resolve spontaneously or in response to medication
ASTHMA CAUSES AND RISK FACTOR
Drugs
Aspirin, NSAID, non-selective beta-blockers
Pollution
ASTHMA
Dust& Pollen
Weather
Perfume& Cosmetic
Cigarettes
COPD CAUSES AND RISK FACTOR
Genetic mutation in the SERPINA1 gene leads to an a-1 antitrypsin (AAT) deficiency. AAT provides protection from damaged caused by inflmmation in the lung
Tobacco smoking and inhalation of toxic particles and gases from household and outdoor air pollution are the main environmental exposure leading to COPD
DIAGNOSIS
Diagnosis for asthma and COPD can be confirmed with using a spirometer. Spirometry assess lung function with various test such as,
An FEV1 increase >12% post-bronchodilator is consistent with asthma diagnosis (considered 'reversible')
Key Differences of Asthma VS COPD
ASSESSMENT OF ASTHMA
Initial assessment
Assessing asthma control after initial assessment
Assessed at each visit using the following four yes/no questions
Sed diam nonummy nibh euismodmagna aliquam erat volutpat"
Author Name
The number of 'YES' determines the level of asthma control:
ASTHMA TREATMENT ALOGORITHM
RESCUE INHALER
MAINTENANCE INHALER
STEPS
As-needed low-dose ICS-FORMoTEROL
low-dose ICS-FORMoTEROL
High-doseICS-formoterol
--
OR
OR
SABA + Low-dose ICS (take together)
--
High-dose ICS-LABA
SABA
As-needed low-dose ICS-FORMoTEROL
--
OR
SABA
Low-dose ICS
Low-dose ics-formoterol
Low-doseICS-formoterol
OR
Low-dose ICS-LABA
SABA
ICS - inhaled corticosteroidSABA - short acting beta agonist LABA - long acting beta agonist
low-dose ICS-FORMoTEROL
Medium-doseICS-formoterol
OR
High-dose ICS-LABA
SABA
Alternative treatments for step:
ASSESSMENT OF COPD
modified British Medical Research Councel (mMRC) Scale: 0-4
COPD assessment includes the following 4 compononet:
COPD Assessment Test (CAT)
Severity of post-bronchodilator airlflow limitation
In patients with FEV1/FVC <0.70
ASSESSMENT OF COPD
COMORBIDITIES
A COPD exacebation is an increase in respiratory symptoms that worsen over less than 14 days. If patient has 2 or more exacerbation per year, they are considered frequent exacerbators. Risk will further increase as airflow limitation worsens and hospitalization for an exacerbation is assocaited with an increase risk of death.
RISK
COPD INITIAL TREATMENT ALOGORITHM
RISK
0 or 1 moderate exacerbation (not leading to hospital admission)
CAT <10mMRC 0-1
CAT >10mMRC ≥2
≥2 moderate exacerbations or ≥1 leading to hospital admission
SYMPTOMS
COPD TREATMENT ESCALATION
Primary Problem
Switch inhaler, check for other casues
LAMA + LABA
LAMA OR LABA
DYSPNEA
COPDNot well controlled
EOS ≥100
EOS < 300
LAMA + LABS + ICS
LAMA + LABA
EOS <100
EXACERBATION(Acute worsening /flare-up)
Consider roflumilast or azithromycin
LAMA OR LABA
EOS ≥ 300
LAMA + LABA +ICS
Long-Acting Beta-2 Agonist
Salmeterol 50mcg/inhalation
Side Effects: Nervousness, Tremor, Tachycardia, Palpitations, Cough, Hyperglycemia, Hypokalemia
Dosing: DPI: 1 inhalation BID
Formoterol 20mcg/2ml nebulizer soln
Dosing: Nebulizer: 20mcg BID MDI: 2 inhalations BID
BOXED WARNING: LABA increase the risk of asthma-related deaths when used alone; should be using with ICS but are not adequately controlled
Short-Acting Beta-2 Agonist
Albuterol 90mcg/inhalation
Side Effects: Nervousness, Tremor, Tachycardia, Palpitations, Cough, Hyperglycemia, Hypokalemia
Dosing: MDI/DPI: 1-2 inhalations q4-6h prn Nebulizer: 1.25-6mg q-5h prn*PO forms are available but not recommended
Levalbuterol 45mcg/inh, nebulizer soln
Dosing: MDI: 1-2 inhalations q4-6h prn Nebulizer: 0.63-1.25mg q6-8h prn
Mechanism of action: relaxes bronchial smooth muscle by selectively binding to beta-2 receptors, leading to bronchodilation
LABA are used for maintenance inhalation only; not for acute bronchospasm
Monitoring: Number of days of SABA use, symptom frequency, peak flow, pulmonary function test, BP, HR, blood glucose, K
Warning: Caution in CVD, glaucoma, hyperthyroidism, seizures, diabets
Mechanism of action: blocks the constricting actions of acethylcholine at M3 muscarinic receptors in bronchial smooth muscle, leading to bronchodilations
Avoid spraying in the eyes; HandiHaler are DPI with capsules, do not swallow by mouth
Monitoring: S/sx at each visit, smoking status, COPD questionnatires, annual spirometry
Warning: Patient with narrow-angle glaucoma, myasthenia gravis, urinary retention, benigh prostatic hyperplasia, and bladder neck obstruction
Long-Acting Muscarinic Antagonist
Short-Acting Muscarinic Antagonist
Tiotropium
Ipratropium bromide 17mcg/inh, 0.02 nebulizer soln
Dosing: DPI: inhale contents of 1 caps via Handihaler device daily (2 puff require) MDI: 2 inbhallations daily
20 mcg ipratropium + 100mcg albuterol/inhalation Nebulizer soln: 0.5 mg ipratropium + 2.5mg albuterol per 3ml
Dosing: Ipratropium: MDI: 2 inh QIDNebulizer: 0.5 mg TID-QID Combivent: MDI: 1 inh QIDnebulizer 3ml QID
Side Effects: Dry mouth, upper respiratory tract infection, cough, bitter taste
Side Effects: Dry mouth, upper respiratory tract infection, cough, bitter taste
INHALED CORTICOSTEROIDS
Mechanism of action: inhibit the inflmmatory response by blocking late-phase reaction to allergens, reduce airway hyperresponsiveness and are potent and effective anti-inflammatory medication.
Rinse mouth and water and spit out after each use to prevent thrush; spacer device with MDI reduce risk
Monitoring: Use of SABA/rescue inhaler, symptom frequency, peak flow, s/sx adrenal insufficiency, s/sx of thrush, bone mineral density
Warning: High doses for prolonged period of time can cause adrenal suppression, increase risk of fractures, growth retardation (in children), and immunosuppression
CONTRAINDICATION: Primary treatment of status asthmaticus or acute episodes of asthma
LAMA/LABA
LAMA/LABA/ICS
ICS/LABA
Budesonide/FormoterolSymbicort Fluticasone/Salmeterol Advair Diskus, Advair HFA Mometasone/Formoterol Dulera Fluticasone/Vilanterol Breo Elipta
No combination LAMA/LABA product are FDA-approved for asthma
ASTHMA
Umeclidinium/Vilanterol/Fluticasone (Trelegy Elipta)
Aclidinium/Formoterol Duaklir PressairGlycopyrolate/Formoterol Bevespi Aerosphere Tiotropium/Olodaterol Stiolto Respimat Umeclidinium/Vilanterol Anoro Elipta
Budesonide/FormoterolSymbicort Fluticasone/Salmeterol Advair Diskus Mometasone/Formoterol Dulera Fluticasone/Vilanterol Breo Elipta
Umeclidinium/Vilanterol/Fluticasone (Trelegy Elipta)Glycopyrrolate/Formeterol/Budesonide (Breztri Aerosphere)
COPD
Non-Pharmacological Management: COPD
Non-Pharmacological Interventions: ASTHMA
Essential: Smoking cessation (can include pharmacological treatment)Pulmonary rehabilitation** Recommended: Physical activity Vaccination: Flu Pneumococcal Pertussis COVID-19 Shingles
** : pulmonary rehabilitation is recommended for patients categorized in only the B and E group during assessment