Medical Treatment Algorithm for Chronic Obstructive Pulmonary Disease
Initial medical treatment of chronic obstructive pulmonary disease (COPD) is guided by severity of obstruction, symptom burden, and exacerbation risk with escalation in therapy targeted to control persistent symptoms or further exacerbations. Exacerbation severity is differentiated by the location of treatment, with moderate exacerbations treated in the outpatient setting with oral corticosteroids, antibiotics, or both and severe exacerbations requiring hospitalization or emergency department care. Additional therapies such as azithromycin and roflumilast can be considered for select patients who continue to experience exacerbations despite optimal inhaled therapy. Further therapies such as azithromycin and roflumilast can be considered in select patients with persistent exacerbations despite maximal inhaled therapy. BMI indicates body mass index, calculated as weight in kilograms divided by height in meters squared; CAT, COPD assessment test; FEV1, forced expiratory volume in the first second of expiration; ICS, inhaled corticosteroid; LABA, long-acting β2-agonist; LAMA, long-acting muscarinic antagonist; SABA, short-acting β2-agonist; SAMA, short-acting muscarinic antagonist.
#COPD #Treatment #Algorithm #Management #Pulmonary #LABA #LAMA #SABA #SAMA #ICS #Pharmacology
Asthma Maintenance Therapy - Stepwise Approach
Low dose ICS
-> Low dose ICS/LABA or Med/High dose ICS
-> Med dose ICS/LABA
-> High dose ICS/LABA
-> High dose ICS/LABA + tiotropium*
Inhaled Corticosteroids (ICS) is the primary maintenance drug of choice in asthma. Here is a review of the stepwise approach in asthma maintenance. Important to remember that all patients should also receive SABA (i.e. albuterol) PRN. The general approach is to start at a low dose ICS, then add on a LABA, then increase the dose of ICS. If uncontrolled on high dose ICS + LABA, tiotropium (LAMA) can be added. Spiriva Respimat is the only LAMA approved for asthma, and it's important to note that this is NOT the same product used in COPD. The device is the same, but the asthma inhaler is half of the dose of the COPD version (asthma version is blue but COPD version is green). As always, assess appropriate adherence, administration technique, and nonpharmacologic management before increasing medication therapy.
#Asthma #Maintenance #Stepwise #Therapy #Management #Pharmacology #Pulmonary
LABA/ICS Combination Inhalers
Long-Acting Beta2 Agonists (LABA) + Inhaled Corticosteroid (ICS) - Commonly used in Asthma
Advair
AirDuo Respiclick
Breo Ellipta
Dulera
Symbicort
Here are the LABA/ICS combination inhalers available - 3 Dry Powder Inhalers (DPI) and 3 HFA inhalers (includes propellant). For the HFA inhalers, they are the traditional type of inhaler that most people think of. These require priming and can be used with a spacer. DPI’s do not have the propellant, so patients need to take a deep quick breath to get the powder into their lungs. These combo LABA/ICS inhalers are very commonly used in asthma, but may also be part of a patients COPD regimen (see one of my old posts for the COPD treatment algorithm). Listed are the normal dosing schedules, but note that each brand has a variety of strengths too.
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One interesting point is that the fluticasone/salmeterol Respiclick is the only one that is available in a generic form. Breo Ellipta is the only one that is dosed 1 puff once daily.
Jarred Prudencio, PharmD - https://www.instagram.com/ambcarerx
#LABAICS #Combination #Inhalers #Naming #Names #Pharmacology #Asthma
First-line therapies for Asthma, Asthma-COPD Overlap and COPD
The diagnosis of COPD, asthma, and ACO initially requires an evaluation of exposure to respiratory risk factors, identification of the type and pattern of respiratory symptoms, and spirometry with a bronchodilator test. If required, specific tests, such as blood analysis with eosinophil counts and IgE levels, bronchoprovocation test, and sensitivity tests for pneumoallergens, can be used. A summary of the differential diagnosis and first-line therapies is depicted.
ACO = asthma-COPD overlap; ICS = inhaled corticosteroids; LABA = long-acting β2-agonist; LAMA = long-acting muscarinic antagonist.
#Diagnosis #Management #ACOPD #Asthma #Overlap #FirstLine #Differences #Algorithm #Treatment
Asthma GINA Guidelines 2019
If Asthma is uncontrolled, first assess for adherence and inhaler technique -Then, increase stepwise therapy:
My last post talked about how to tell if your patients asthma is uncontrolled, now this one will talk about what to do if it is! First step is to assess patients adherence to maintenance inhalers (if any) and appropriate inhaler technique. Many times, appropriate teaching can help improve patients breathing. If it is still uncontrolled, you can increase patients inhaler regimen accordingly with these 5 steps. Start with just a rescue inhaler, then a low dose ICS, then step up to ICS/LABA combos and increase the strength of the ICS. Lastly we can use tiotropium or biologics if needed. One big thing to note here with 2019 guidelines is that they are now recommending low dose ICS+formoterol (i.e. Symbicort) as a rescue inhaler for Step 1 instead of a traditional albuterol!
Jarred Prudencio, PharmD - https://www.instagram.com/ambcarerx
#Asthma #Stepwise #Guidelines #Management #StepUp #Therapy
Long-Acting Muscarinic Antagonists - LAMA (Anticholinergic) Inhalers
Ipratropium -(Atrovent)
Umeclidinium (Incruse Ellipta)
Tiotropium (Spiriva Respimat)
Aclidinium (Tudorza Pressair)
LAMA inhalers, otherwise known as Anticholingeric inhalers, are common first-line agents used in COPD management. Specifically in patients with GOLD Groups A, B, or C, LAMA monotherapy is an appropriate first line (check out one of my old posts for a review on how to classify patients into these groups). We have 3 true long-acting inhalers, but Atrovent (ipratropium) can also be used in this indication. However, it requires QID dosing which can be very hard for patients.
Jarred Prudencio, PharmD - https://www.instagram.com/ambcarerx
#LongActing #Muscarinic #Antagonists #LAMA #Anticholinergic #Inhalers #Pharmacology #COPD
