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Respiratory Update_Handout - American Pharmacists Association
Respiratory Update: Guidelines, Novel Inhalers and More Dennis Williams, PharmD, BCPS, FAPhA University of North Carolina Eshelman School of Pharmacy Chapel Hill, North Carolina Michael J. Cawley, PharmD., RRT, CPFT, FCCM Philadelphia College of Pharmacy / University of the Sciences Philadelphia, PA 2 Supporter Disclosures • Supported by an independent educational grant from • Dennis Williams reports that his spouse is an employee AstraZeneca LP. of GlaxoSmithKline and also holds stock in the company • Michael J. Cawley: “declare(s) no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.” The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. 3 4 Learning Objectives • Classify symptom severity, assess control, and select and • Target Audience: Pharmacists • ACPE#: 0202-0000-16-050-L01-P • • Activity Type: Application-based • • • 5 © 2016 by the American Pharmacists Association. All rights reserved. monitor appropriate therapy for patients with asthma or COPD Given representative patient cases, develop care plans for patients with asthma or COPD based on current guidelines for assessing and treating patients Discuss current and emerging therapeutic options for the management of asthma and COPD Discuss patient related factors to consider when selecting among available inhaler devices Demonstrate how to use devices for the management of asthma and COPD and educate patients on proper use 6 The most important and prognostic spirometry parameter to assess in COPD for disease severity and progression is the The frequency of use of which of the following medications is a good indicator of current asthma control? A. Budesonide B. Salmeterol C. Albuterol D. Montelukast A. Peak expiratory flow rate (PEF) B. Forced vital capacity (FVC) C. Forced expiratory volume in 1 second (FEV1) D. Residual volume (RV) 7 8 Which of the following therapeutic options is FDA approved for both asthma and COPD? Foundational treatment for asthma focuses on _______ therapy and the focus of COPD treatment is on ___________therapy. A. Bronchodilator, corticosteroid B. Bronchodilator, bronchodilator C. Corticosteroid, bronchodilator D. Corticosteroid, corticosteroid A. B. C. D. Tiotropium (Spiriva Respimat) Aclidinium (Tudorza Pressair) Umeclidinium (Incruse Ellipta) Albuterol/Ipratropium (Combivent) 9 Which of the following is/are patient related factors to consider when selecting an inhaler device? Asthma • Asthma is a common chronic disorder of the airways that is A. Age, physical and • cognitive abilities B. Availability of drug C. Cost of the drug and device D. All of the above complex and characterized by variable and recurring symptoms Features of asthma include – airflow obstruction – bronchial hyperresponsiveness – inflammation • The interaction of these features of asthma determines the clinical manifestations and severity of asthma and the response to treatment 11 © 2016 by the American Pharmacists Association. All rights reserved. 10 12 Asthma Pathophysiology Clinical Management of Asthma Susceptible Person is Exposed to Trigger Leading Airway Mucosal Inflammation Numerous Cells and Mediators are Activated To Airway Hyperresponsiveness Resulting BronchospasmIn Airway Hyperreactivity Increased Mucus Production Causing Wheezing Cough Shortness of Breath Chest Tightness EPR 3; NAEPP; NHLBI 2007 13 GINA Guidelines; NHLBI and WHO 2015 Source: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf Robin Robin • Robin is an 11 year old Caucasian male who is brought to • According to his parents, the patient developed a head • the clinic by his parents after a visit to the emergency department last evening because of an acute asthma episode He was treated with albuterol and oxygen and discharged on an albuterol MDI and prednisone for 5 days, and advised to come to the clinic today cold about 3 days prior which moved into his chest • Yesterday, he began coughing and complaining of chest tightness and shortness of breath • His parents could hear wheezing in his chest and took him to the emergency department 15 16 Robin Robin • His PMH is relatively unremarkable. He has had nasal • He is a moderately obese male, 50 kg and 56 inches tall allergies since age 7 for which he uses loratadine as needed. His mom feels that his allergies are more of a problem in the spring when the pollens are present. 14 who appears healthy and in NAD • Vitals are WNL and he is afebrile • Scattered and diffuse wheezes are present on auscultation • Peak flow is measured at 235 (predicted is 300). Spirometry is not performed • Pulse oximetry is 96% 17 © 2016 by the American Pharmacists Association. All rights reserved. 18 What should be considered now regarding therapy? A. Continue chronic low dose prednisone B. Start an inhaled corticosteroid C. Start a leukotriene modifier D. Continue the rescue inhaler and monitor EPR-3, Oct 2007. NIH Pub # 08-5846 http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf 19 20 Robin • The family is advised to finish the prednisone, use albuterol for any subsequent symptoms and to RTC in one month • He is also instructed to continue to use his loratadine when needed • The patient is a no show for his one month followup • A refill request for albuterol is received at 6 weeks 21 A. Refill the albuterol B. Switch to levalbuterol C. Start salmeterol D. Consider a long term • The family is contacted and returns for a visit • They report that Robin has not experienced any more episodes as severe as before • He has experienced some shortness of breath with physical activity but the albuterol seems to help with that • He wakes up about once a week or less complaining of control therapy shortness of breath but returns to sleep after using his inhaler His peak flow in the clinic is 270 23 © 2016 by the American Pharmacists Association. All rights reserved. 22 What’s the best action now? Robin • EPR-3, Oct 2007. NIH Pub # 08-5846 http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf 24 Components of Asthma Management Stepwise treatment, Ages 5-11 • Assessment and monitoring • Patient education • Control of environmental factors and comorbid conditions • Pharmacotherapy Adapted from EPR-3, Oct 2007. NIH Pub # 08-5846 http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf 25 26 Asthma: Assessment and Monitoring Check Points • • • • • Adherence with therapy Optimal inhalation technique Avoidance of triggers and aggravating conditions Vaccines up to date Provision of asthma action plan 27 • Bob Davis is a 34 year old male with mild persistent asthma treated with budesonide 180 mcg twice daily and PRN albuterol. He indicates that he has had mild asthma his entire life and that the only thing that makes it worse is cigarette smoke. Sometimes he gets symptoms with exercise which he doesn’t do very often. He feels that his asthma was well controlled in the past and estimates that he uses his albuterol 3 or 4 times a month. 29 © 2016 by the American Pharmacists Association. All rights reserved. 28 More about Bob Bob • EPR-3, Oct 2007. NIH Pub # 08-5846 http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf • Recently, he has noticed that his symptoms are occurring • more frequently, requiring him to use albuterol almost daily. The increased symptoms are limiting his ability to exercise and play tennis. Last evening, his symptoms acutely worsened and he went to an urgent care center where he received nebulized albuterol and a 5 day course of prednisone 40 mg. 30 What advice is appropriate for Bob now? A. Hang in there and tough it out B. Increase the budesonide C. Add a LABA D. Add a leukotriene modifier EPR-3, Oct 2007. NIH Pub # 08-5846 http://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf 31 Asthma: Assessment and Monitoring Check Points • • • • • Adherence with therapy Optimal inhalation technique Avoidance of triggers and aggravating conditions Vaccines up to date Provision of asthma action plan 32 Stepwise Approach to Managing Asthma in Individuals ≥12 Years of Age Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3 Step 6 Step 4 Step 2 Preferred: Low-dose ICS Alternative: LTRA Step 1 Cromolyn Preferred: Theophylline SABA prn Step 3 Preferred: Low-dose ICS +LABA OR Medium-dose ICS Alternative: Low-dose ICS + either LTRA, Theophylline Or Zileuton Preferred: Medium-dose ICS+LABA Step 5 Preferred: High dose ICS + LABA Preferred: High-dose ICS + LABA + oral Corticosteroid AND AND Alternative: Medium-dose Consider Consider ICS+either Omalizumab for Omalizumab for LTRA, patients with patients with Theophylline allergies allergies Or Zileuton Or ICS/tiotropium Step up if needed (check adherence, environment -al control and comorbidities) Assess Control Step down if possible (asthma well controlled for 3 months) Or add tiotropium to ICS/LABA Provide Patient Education and Environmental Control Advice at Each Step 33 Add LABA to ICS therapy Increase ICS dose Add a leukotriene modifier Add tiotropium Monitor for effectiveness and safety A. Influenza B. Pneumococcal C. Hepatitis B D. All of the above E. Both 1 and 2 above 35 © 2016 by the American Pharmacists Association. All rights reserved. 34 What vaccines should be considered for Bob based on his asthma diagnosis? Options for Bob • • • • • Adapted from National Heart, Lung and Blood Institute. EPR 3 Guidelines; 2007. 36 Inflammation in COPD Chronic Obstructive Pulmonary Disease “Chronic Obstructive Pulmonary Disease (COPD), a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.” Generates Burning Hydrocarbons Activates Respiratory Tract Macrophages Release Release Neutrophils Proteases Resulting in Airway and Parenchymal Damage 2013 GOLD Guidelines. www.goldcopd.org 37 Ray—The Case Study Ray—The Case Study • Ray is a 63 year-old male known to have COPD who visits • • 38 his clinician because he feels that his albuterol/ipratropium inhaler is not working well The patient was diagnosed with COPD five years ago attributed to a 48 pack year smoking history (Continues to smoke about ¾ PPD) Patient is s/p MI three years ago and treated with metoprolol, lisinopril, and furosemide • Over the past few months, Ray has noticed decreased exercise tolerance • He gets SOB easily and feels that his albuterol/ipratropium is • • • not working as well as it has in the past. He uses it PRN and has often required it three or four times daily He has not been hospitalized or in the ED because of his COPD His physical exam is relatively unremarkable and his chest xray shows some scarring consistent with his tobacco history Pulse oximetry is 91% and spirometry reveals: – FEV1 is 2.4 L (72% predicted); FVC is 3.49 L (85% predicted) with a ratio of 69% 39 Global Initiative for Chronic Obstructive Pulmonary Disease 40 Combined Assessment of COPD • Available at www.goldcopd.com • Three components determine severity – Spirometry to assess degree of airflow limitation – Symptoms assessment (various tools) – Risk for exacerbations • First version published in 2001 • Most recent update: 2015 41 © 2016 by the American Pharmacists Association. All rights reserved. 42 Global Strategy for Diagnosis, Management and Prevention of COPD Spirometry is essential for diagnosis of COPD and monitoring progression I: Mild FEV1/FVC < 0.70 30% ≤ FEV1 < 50% predicted II: Moderate III: Severe IV: Very Severe 2 Score 0 Only breathlessness with strenuous exercise Mild 1 Short of breath hurrying or walking up a slight hill Moderate 2 Walks slower than age group or has to stop for breath when walking on the level at own pace Severe 3 Stops for breath after walking 100 meters or a few minutes on the level Very Severe 4 Breathless when dressing/undressing or too breathless to leave the house (A) (B) 1 0‐1 (not leading to hospital admission) CAT < 10 CAT > 10 Symptoms mMRC > 2 mMRC 0–1 Breathlessness 44 © 2014 Global Initiative for Chronic Obstructive Lung Disease MMRC Questionnaire: Breathlessness Self-Assessment None (D) 3 American Thoracic Society, European Respiratory Society. Standards for the diagnosis and Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of COPD. Updated 2015 Severity (C) ≥ 2 or > 1 leading to hospital admission Risk FEV1/FVC < 0.70 50% ≤ FEV1 < 80% predicted 4 (Exacerbation history) FEV1/FVC < 0.70 FEV1 ≥ 80% predicted FEV1/FVC < 0.70 FEV1 <30% predicted OR FEV1 <50% predicted PLUS chronic respiratory failure Risk Post-bronchodilator FEV1 is recommended for the assessment of COPD severity (GOLD Classification of Airflow Limitation) Combined Assessment of COPD COPD Assessment Test™ (CAT)* • Eight questions; 5-point scale • (0 = least severe; 5 = most severe) Level of Breathlessness – – – – – – – – Cough Phlegm (mucus) Chest tightness Breathless walking up a hill or one flight of stairs Activity limitations Confident to leave home Sleep Energy • Assessment – Minimum score: 0 – Maximum score: 40 MMRC patient questionnaire available at http://copd.about.com 45 Treatment Goals: Stable COPD Reduce Symptoms Reduce Risks • Relieve symptoms • Improve exercise tolerance • Improve overall health status • Prevent disease progression • Prevent and treat exacerbations • Reduce mortality • Prevent and treat complications • Minimize side effects 47 2013 GOLD Guidelines. www.goldcopd.org © 2016 by the American Pharmacists Association. All rights reserved. * This assessment tool is a trademark of the GlaxoSmithKline group of companies.46 What is your recommendation for Ray? A. Add tiotropium B. Add salmeterol C. Continue albuterol/ipratropium D. Add budesonide/formoterol 48 Pharmacotherapy Recommendations for COPD Patient Group (Classification) A Alternative Choices Other Options • Short-acting anticholinergic PRN • Long-acting anticholinergic • Long-acting β2 agonist • Short-acting β2 agonist and short-acting anticholinergic in combo • Theophylline • Long-acting anticholinergic plus Long-acting β2 agonist • Short-acting anticholinergic PRN • Short-acting β2 agonist PRN • Combo of two above • Theophylline • Long-acting anticholinergic plus Long-acting β2 agonist • Short-acting anticholinergic PRN • Short-acting β2 agonist PRN • Combo of two above • Theophylline • Short-acting β2 agonist PRN B • Long-acting anticholinergic • Long-acting β2 agonist C • Inhaled corticosteroid plus long-acting β2 agonist • Long-acting anticholinergic • Either of the above agents with phosphodiesterase-4 inhibitor D Summary Recommended 1st Choices • Inhaled corticosteroid plus long-acting β2 agonist • Long-acting anticholinergic • Combo of both above • • • • Inhaled corticosteroid plus longacting β2 agonist and long-acting anticholinergic Inhaled corticosteroid plus longacting β2 agonist and phosphodiesterase-4 inhibitor Long-acting anticholinergic and long-acting β2 agonist Long-acting anticholinergic plus phosphodiesterase-4 inhibitor • National and international guidelines are available for advice about managing asthma and COPD • • • • • • Numerous therapeutic options exist for each condition • The focus of asthma therapy is on corticosteroids while COPD focuses on bronchodilators • Inhalational routes are the preferred and common methods for managing asthma and COPD Short-acting β2 agonist Short-acting anticholinergic Combo of two above Carbocysteine Theophylline 49 50 Patient Case Patient Case (cont.) • Richard is a 54-year-old male with COPD presents to his family physician with increased SOB over the past 2 weeks • Medical problems include hyperlipidemia and broken right arm (full arm cast) due to recent construction accident • Smoker (36 pack year history) • Occupational history as a construction laborer x 20 years • Presently the patient is prescribed an albuterol inhaler PRN and simvastatin 20 mg daily • Patient received both influenza and pneumococcal vaccine last month • Over the past few weeks, his SOB has increased, requiring use of his albuterol inhaler up to 4x per day, with some relief • He has required 3 hospital visits due to his breathing within the last 12 months • His physical exam is unremarkable; however, during auscultation and percussion, a decrease in breath sounds is noted SOB = shortness of breath; PRN = as needed. 51 52 Which of the following would be required to determine a category assessment of COPD? A. B. C. D. Current and Emerging Therapeutic Options for Asthma and COPD Spirometry testing History of COPD exacerbation CAT score All of the above 53 © 2016 by the American Pharmacists Association. All rights reserved. 54 Current Inhaled Medications for Asthma/COPD Current Inhaled Medications for Asthma/COPD Medication Brand Starting Dose (inhalations) Medication Asthma / COPD β2-Agonists ProAir, Proventil, Ventolin, ProAir RespiClick Levalbuterol Xopenex HFA 2 q 4-6 hrs Asthma/COPD 2 q 4-6 hrs Asthma Long-acting Formoterol Starting Dose (inhalations) Asthma/COPD Anticholinergics Short-acting Albuterol Brand Foradil Aerolizer, Perforomist, Brovana 1 inh cap bid Indacaterol Arcapta Neohaler 1 inh cap daily Salmeterol Serevent Diskus Olodaterol Striverdi Respimat Asthma/COPD Atrovent 2 qid COPD Aclidinum Tudorza Pressair 1 bid COPD Tiotropium Spiriva HandiHaler 1 inh cap daily COPD Spiriva Respimat 2 daily Asthma/COPD Umeclidinium Incruse Ellipta 1 daily COPD Glycopyrrolate Seebri Neohaler 1 inh cap bid COPD Combination agents Albuterol/ipratropium Combivent 2 q4-6 hrs COPD COPD Umeclidinum/vilanterol Anoro Ellipta 1 daily COPD 1 bid Asthma/COPD Olodaterol/tiotropium Stiolto Respimat 2 once daily COPD Indacaterol/glycopyrrolate Utibron Neohaler HFA = hydrofluoroalkane; Food and Drug Administration. Drugs@FDA. https://www.accessdata.fda.gov/scripts/cder/drugsatfda/ Current Inhaled Medications for Asthma/COPD Brand Starting Dose (inhalations) 2 daily COPD 1 inh cap bid COPD Food and Drug Administration. Drugs@FDA. https://www.accessdata.fda.gov/scripts/cder/drugsatfda/ 55 Accessed November 2015 Medication Ipratropium Accessed November 2015 56 Current Oral Medications for Asthma/COPD Asthma/COPD Medication Inhaled Corticosteroids Brand Usual Starting Dose Asthma/COPD Corticosteroids Budesonide Pulmicort Flexhaler 1-2 bid Asthma/COPD Methylprednisolone 4-48mg/day depending on Asthma/COPD disease and response Fluticasone Flovent HFA 1-2 bid Asthma/COPD Prednisolone Beclomethasone QVAR 1-2 bid Asthma/COPD 5-60mg/day depending on Asthma/COPD disease and response Ciclesonide Alvesco 1-2 bid Asthma/COPD Prednisone 5-60mg/day depending on disease and response Symbicort Combination Inhalers Formoterol/budesonide 2 bid Asthma/COPD Mometasone/formoterol Dulera 2 bid Asthma Fluticasone/salmeterol Advair Diskus Advair HFA 1 bid 2 bid Asthma/COPD Fluticasone/vilanterol Breo Ellipta 1 daily Asthma/COPD HFA = hydrofluoroalkane; Food and Drug Administration. Drugs@FDA. https://www.accessdata.fda.gov/scripts/cder/drugsatfda/ Accessed November 2015 57 Asthma/COPD PDE4 Inhibitor Roflumilast Daliresp One 500 mcg tablet by mouth daily COPD Food and Drug Administration. Drugs@FDA. https://www.accessdata.fda.gov/scripts/cder/drugsatfda/ Accessed November 2015 58 Incorrect Inhaler Technique • 28-68% of patients do not use MDIs or DPIs correctly • Even with optimal use of any aerosol delivery system, lung deposition may range from 10-15% of the total medication dose Respiratory Delivery Devices and Proper Inhaler Technique • Worsening pulmonary symptoms may not always indicate disease progression but may indicate inability to use inhaler device optimally • Instructing patient in the essential steps in drug delivery with device and observe patient demonstrating are key factors for patient success American Association for Respiratory Care Guide to Aerosol Delivery Devices. 59 © 2016 by the American Pharmacists Association. All rights reserved. https://c.aarc.org/resources/aerosol_nonrts.pdf. Accessed Nov 2015 60 Errors with Specific Inhaler Devices Criteria for Selecting an Aerosol Delivery Device • pMDI – Failure to shake and prime the device • Patient related factors – Failure to coordinate pMDI depression (actuation) on inhalation • Drug related factors – Age, physical and cognitive abilities • pMDI with spacer – Delay between actuation and inhalation • • Dry-powder inhalers – Failure to pierce or open drug package • – Exhaling through the mouthpiece – Not inhaling forcefully enough American Association for Respiratory Care Guide to Aerosol Delivery Devices. https://c.aarc.org/resources/aerosol_nonrts.pdf. Accessed Nov 2015 61 – Availability of drug – Combination of aerosol treatments Device related factors – Convenience, durability, cost and reimbursement of aerosol generator Environmental and clinical factors – When and where aerosol therapy is required American Association for Respiratory Care Guide to Aerosol Delivery Devices. https://c.aarc.org/resources/aerosol_nonrts.pdf. Accessed Nov 2015 62 Respiratory Delivery Devices Respiratory Delivery Devices HandiHaler (tiotropium bromide) ProAir RespiClick (albuterol sulfate) 1. Dust cap 2 2. Mouthpiece 3. Base 1 5 4 3 RxList: The internet drug index http://www.rxlist.com/proair-respiclick-drug/medicationguide.htm 63 Respiratory Delivery Device 4. Green piercing button 5. Center chamber Personal photograph: September 2015 64 Respiratory Delivery Device Breo Ellipta (fluticasone furoate/vilanterol) Incruse Ellipta (umeclidinium) Anoro Ellipta (umeclidinium/vilanterol) Arcapta Neohaler (indacaterol inhalation powder) Seebri Neohaler (glycopyrrolate) Utibron Neohaler (indacaterol/glycopyrrolate Mouthpiece Air Vent Counter Personal Photograph: September 2015 © 2016 by the American Pharmacists Association. All rights reserved. Cover 65 Personal Photograph: August 2015 66 Respiratory Delivery Device Respiratory Delivery Device • Respimat Soft Mist Inhaler Stiolto Respimat (olodaterol/tiotropium) Mouthpiece Turn transparent base until it clicks Cap Dose release button Insert mouthpiece into mouth and while taking a deep breath, press the dose-release button and continue to breathe in. Cartridge Transparent base Personal Photograph: August 2015 67 Respiratory Delivery Device Food and Drug Administration. Drugs@FDA. http://www.accessdata.fda.gov/scripts/cder/ drugsatfda/index.cfm. http://experts.respimat.com/functions_and_use/components_of_Respimat.html 68 Clinical Case – Back to Richard Tudorza Pressair (aclidinium bromide) Richard has improved with the addition of fluticasone/vilanterol inhaler, however is still needing to use his albuterol 3x daily. Dose button Dose indicator Colored dose window The pharmacist recommends adding a long‐acting anticholinergic to his present regimen Mouthpiece Protective Cap Personal Photograph: August 2015 69 Which of the following long‐acting anticholinergics would be the most optimum selection(s) for Richard at this time? 70 Question – Follow‐up HandiHaler A Respimat B A. Tiotropium (Handihaler) or umeclindinium B. Tiotropium (Respimat) or umeclindinium C. C. Aclidinium or umeclindinium D. D. All of the above Tudorza / Pressair C 71 © 2016 by the American Pharmacists Association. All rights reserved. Richard has a broken right arm. Inserting medication capsule in device A or twisting device B would be difficult. Ellipta D Pushing the button of device C or opening cover of device D would be most optimum. 72 Common Errors with Inhalers Inhaler Use – House MD • Unfamiliar with device • Failure to hold breath for sufficient time after drug delivery • Multiple actuations without waiting or shaking in between doses • Incorrect position of device • Failure to breathe deeply and with enough force to deliver medication (dry power inhalers) • Exhaling into device American Association for Respiratory Care Guide to Aerosol Delivery Devices. https://c.aarc.org/resources/aerosol_nonrts.pdf. Accessed October, 2015 • Review device instructions and practice with placebo device • Demonstrate assembly and correct use of device using a checklist • Provide the patient written instructions on how to use the device • Have patient practice using the device while being observed • Review patients understanding of the inhaled medication at each return visit (when to use, purpose of drug, prescribed frequency) • If poor management of airway disease occurs suspect incorrect use or non-adherence 75 Key Points • Asthma and COPD are chronic respiratory diseases • • • requiring a focus on preventing exacerbations and maintaining improved quality of life Selection of appropriate pharmacotherapy and inhalational device is an essential component of management Pharmacists should continually educate themselves on new pharmacotherapeutic options and aerosol delivery devices Pharmacists must work with patients to assist with aerosol delivery device technique and strategies to maintain compliance 77 © 2016 by the American Pharmacists Association. All rights reserved. 74 Potential Roles for Pharmacists in Assisting Patients With Asthma and COPD Strategies for Correct Inhaler Technique American Association for Respiratory Care Guide to Aerosol Delivery Devices. https://c.aarc.org/resources/aerosol_nonrts.pdf. Accessed October, 2015 https://www.youtube.com/watch?v=nvwR74XpKUM 73 • • • • • • • • Help identify existing asthma “triggers” and how to avoid them Create an asthma control plan with physician Advising and assisting with tobacco cessation Recommending and administering vaccines Monitoring and educating to improve adherence and correct inhaler technique Ensuring optimal pharmacotherapy to meet goals Providing medication therapy management services Performing spirometry testing American Pharmacists Association Foundation. J Am Pharm Assoc. 2011;51(2):203211. Cawley MJ, et al. J Am Pharm Assoc. 2013;53(3):307-315 76 The most important and prognostic spirometry parameter to assess in COPD for disease severity and progression is the A. Peak expiratory flow rate (PEF) B. Forced vital capacity (FVC) C. Forced expiratory volume in 1 second (FEV1) D. Residual volume (RV) 78 The frequency of use of which of the following medications is a good indicator of current asthma control? Foundational treatment for asthma focuses on _______ therapy and the focus of COPD treatment is on ___________therapy. A. Budesonide B. Salmeterol C. Albuterol D. Montelukast A. Bronchodilator, corticosteroid B. Bronchodilator, bronchodilator C. Corticosteroid, bronchodilator D. Corticosteroid, corticosteroid 79 Which of the following is/are patient related factors to consider when selecting an inhaler device? Which of the following therapeutic options is FDA approved for both asthma and COPD? A. B. C. D. 80 A. Age, physical and Tiotropium (Spiriva Respimat) Aclidinium (Tudorza Pressair) Umeclidinium (Incruse Ellipta) Albuterol/Ipratropium (Combivent) cognitive abilities B. Availability of drug C. Cost of the drug and device D. All of the above 81 © 2016 by the American Pharmacists Association. All rights reserved. 82
