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2/7/2019
1
END-STAGE COPD: Huffing and Puffing over
Treatment Options
KRISTIN SPEERPHARM.D., BCPS, cMTM
HOSPICE & PALLIATIVE CARE CLINICAL PHARMACIST
FEBRUARY 12-13, 2019
Cost Effective Medication Management in End Stage COPD
Conflict of Interest and Disclosures of Relevant Financial
Relationships
The planners and presenters (spouse/domestic partner) of this educational activity have disclosed no healthcare related conflicts of interest, commercial interest, or have any related financial relationships/support.
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
2
Contact Hours –Nursing
1.0 Contact Hour
ProCare Hospice Care is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. (P-0544, 3/31/2021)
Successful Completion Criteria
• Register for theactivity
• Complete and submitthe sign in sheet
• View the entirepresentation
• Complete and submitthe participantevaluation
• Certificate will beemailed uponcompletion of thecriteria
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
3
Objectives
1. Select cost-effective treatments for the management ofdyspnea due to COPD in end of life
2. Determine the efficacy and safety of certain oral COPDmedications for end-of-life patients
3. Develop a breathing treatment regimen that negotiatesand resolves the COPD patient’s resistance to “letting go”of inhalers
5
Discussion Outline
What basic regimen is cost effective and will work for most patients?
If you want to get technical (and not use basic/empiric regimen)
Cost comparison
Case: COPD new admission
When would the basic regimen not be appropriate?
Case: COPD with tachycardia/tremors
Case: COPD with fluid overload
What else will work well for many patients?
Case: COPD exacerbation, already on basic regimen
What about antibiotics/criteria for use
Continue Daliresp® (roflumilast) or theophylline?
Case: New COPD admission, hesitant about nebs
Proper Inhaler Technique 6
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
4
What Cost-Effective ‘Basic Regimen’ Will Work for Most Patients?
Regardless of current inhaler regimen:
1. Scheduled + PRN nebs (using albuteroland/or ipratropium for most)
2. +/- oral steroids*
7
*prednisone, dexamethasone and methylprednisolone are preferred
Putting it together:
1. Scheduled + PRN albuterol/ipratropium
2. +/- prednisone, dexamethasone ormethylprednisolone
8
Why would this work for most patients?
What Cost-Effective ‘Basic Regimen’ Will Work for Most Patients?
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
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9
New Regimen Takes Place Of:
Scheduled nebs Long-Acting Inhaler(s) (Controller)
PRN nebs Short-Acting Inhaler(s) (Rescuer)
Oral steroid Inhaled steroid
What Cost-Effective ‘Basic Regimen’ Will Work for Most Patients?
Nebulizer Overview
10
https://my.clevelandclinic.org/health/drugs/4254-home-nebulizer
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
6
Less than half of patients in the general population are able to use their prescribed inhalers adequately1.
What % of hospice patients would you guess are able to use their inhalers adequately?
11
If You Want to Get Technical
12
If on this: Choose this:Advair Diskus® (fluticasone/salmeterol) Scheduled albuterol +/- oral steroid
Symbicort® (budesonide/formotorol) Scheduled albuterol +/- oral steroid
Perforomist® (aformotorol) Scheduled albuterol
Pulmicort® (budesonide) inhaler or nebs Oral steroid
Trelegy Ellipta® (fluticasone/umeclidinium/vilanterol)
Scheduled albuterol/ipratropium +/- oral steroid
Breo Ellipta® (fluticasone/vilanterol) Scheduled albuterol +/- oral steroid
Combivent Respimat® (albuterol/ipratropium)
Scheduled albuterol/ipratropium
Spiriva HandiHaler® (tiotropium) Scheduled ipratropium
If you prefer not to use DuoNeb® empirically…
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
7
If You Want to Get Technical
13
Q: What if I started scheduled DuoNeb®, and the chart says something else?
If no clinical contraindications (most patients don’t have any), the extra component in DuoNeb® that the patient was not getting from their inhaler will likely add benefit without significant side effects.
If You Want to Get Technical
14
Decide in the field using this trick: look at generic names on inhalers
“IUM” = “IUM” (give ipratropIUM neb)
“ROL” = “ROL” (give albuteROL neb; OR albuteROL/ipratroIUM if “IUM” also present)
“ONE” = “ONE” (may give oral steroid)
IpratroIUM neb = Atrovent® nebAlbuteROL neb = Ventolin® neb, Proventil® nebIpratropIUM/AlbuteROL neb – DuoNeb®
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
8
Cost Comparison* - Inhalers:
15
Inhaler Retail CostAdvair Diskus ® (fluticasone/salmeterol) $400 (30d)
Symbicort ® (budesonide/formoterol) $330 (30d)
Foradil ® (aformoterol) $300 (30d)
Pulmicort Flexhaler ® (budesonide) $300 (30d)
Trelegy Ellipta ® (fluticasone/umeclidinium/vilanterol) $630 (30d)
Breo Ellipta ® (fluticasone/vilanterol) $420 (30d)
Combivent Respimat ® (albuterol/ipratropium) $450 (30d)
Spiriva HandiHaler ® (tiotropium) $470 (30d)
Ipratropium/albuterol neb + oral steroid $60 for 15 days
*Current approx. retail costs from Goodrx.com. Actual costs to hospice are per pharmacy contracts and will vary.
16
High Cost Nebs Retail CostLonhala Magnair® (glycopyrrolate) $1,460 (30d kit)
Pulmicort® (budesonide) $250 (15d)
Brovana® (arformoterol) $600 (15d)
Perforomist® (formoterol) $550 (15d)
Xopenex® (levalbuterol) $350 (15d)
Ipratropium/albuterol neb + oral steroid $60 for 15 days
*Current approx. retail costs from Goodrx.com. Actual costs to hospice are per pharmacy contracts and will vary.
Cost Comparison* - Nebs:
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
9
Case: COPD New Admission
78 year old female with severe COPD and PMH of CHF and CKD. Receiving Spiriva® (tiotropium), Advair® (fluticasone/salmeterol), and Breo Ellipta® (fluticasone/vilanterol). Completed 5 days prednisone in hospital, and discharged with DuoNeb® (ipratropium/albuterol) PRN orders, which she is hesitant to use. Symptoms remain uncontrolled.
A) Why do you suspect her symptoms remain uncontrolled?
B) Can you identify duplication of therapies?
C) What cost-effective breathing regimen should we switch to?
17
Case: COPD New Admission
78 year old female with severe COPD and PMH of CHF and CKD. Receiving Spiriva® (tiotropium), Advair® (fluticasone/salmeterol), and Breo Ellipta® (fluticasone/vilanterol). Completed 5 days prednisone in hospital, and discharged with DuoNeb® (ipratropium/albuterol) PRN orders, which she is hesitant to use. Symptoms remain uncontrolled.
A) Why do you suspect her symptoms remain uncontrolled?
Likely poor inhaler technique!
18
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
10
Case: COPD New Admission
78 year old female with severe COPD and PMH of CHF and CKD. Receiving Spiriva® (tiotropium), Advair® (fluticasone/salmeterol), and Breo Ellipta® (fluticasone/vilanterol). Completed 5 days prednisone in hospital, and discharged with DuoNeb® (ipratropium/albuterol) PRN orders, which she is hesitant to use. Symptoms remain uncontrolled.
B) Can you identify duplication of therapies?
Trick: look at generic names – IUM? ROL? ONE?
19
Case: COPD New Admission
78 year old female with severe COPD and PMH of CHF and CKD. Receiving Spiriva® (tiotropium), Advair® (fluticasone/salmeterol), and Breo Ellipta® (fluticasone/vilanterol). Completed 5 days prednisone in hospital, and discharged with DuoNeb® (ipratropium/albuterol) PRN orders, which she is hesitant to use. Symptoms remain uncontrolled.
C) What cost-effective breathing regimen should we switch to?
Remember: start with “what will work for most patients”; can adapt this regimen
20
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
11
(Reminder):
1. Scheduled + PRN albuterol/ipratropium
2. +/- prednisone, dexamethasone ormethylprednisolone
21
What Cost-Effective ‘Basic Regimen’ Will Work for Most Patients?
When Would that Basic Regimen NOT Work or be Appropriate?
Adverse reaction (but weigh risk vs benefit!)
Albuterol – possible tachycardia, tremors, anxiety
Oral steroid – possible anxiety/stimulation/insomnia, edema, etc.
Goals of care that preclude nebulizer treatments
Visiting/activities outside of the house/QOL
Goals of care that preclude steroid use
Wound healing
Fluid/edema control (though can still use dexamethasone!)
Glucose control? -does not usually preclude steroid use22
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
12
Case: COPD with Tachycardia/Tremors
23
78 year old female with severe COPD and PMH of CHF and CKD. Increased wheezing due to decline. Albuterol/ipratropium (DuoNeb®) scheduled + PRN not well-tolerated due to symptomatic tachycardia and tremors/shakiness. They seem to work when taken, but patient is limiting use due to the adverse reactions.
A) What component of the neb tx is causing tachycardia/tremors?
B) What neb txs can we switch the patient to?
C) Which new neb tx is more cost-effective?
Case: COPD with Tachycardia/Tremors
78 year old female with severe COPD and PMH of CHF and CKD. Increased wheezing due to decline. Albuterol/ipratropium (DuoNeb®) scheduled + PRN not well-tolerated due to symptomatic tachycardia and tremors/shakiness. They seem to work when taken, but patient is limiting use due to the adverse reactions.
A) What component of the neb tx is likely causing tachycardia/tremors?
Beta agonist! (ROL) - albuterol
24
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
13
Case: COPD with Tachycardia/Tremors
78 year old female with severe COPD and PMH of CHF and CKD. Increased wheezing due to decline. Albuterol/ipratropium (DuoNeb®) scheduled + PRN not well-tolerated due to symptomatic tachycardia and tremors/shakiness. They seem to work when taken, but patient is limiting use due to the adverse reactions.
B) What neb txs can we switch the patient to?
A special beta agonist (levalbuteROL neb) (Xopenex® neb)
Anticholinergic only (ipratropIUM neb) (Atrovent® neb)
25
Case: COPD with Tachycardia/Tremors
78 year old female with severe COPD and PMH of CHF and CKD. Increased wheezing due to decline. Albuterol/ipratropium (DuoNeb®) scheduled + PRN not well-tolerated due to symptomatic tachycardia and tremors/shakiness. They seem to work when taken, but patient is limiting use due to the adverse reactions.
C) Which new neb tx is more cost-effective?
A special beta agonist (levalbuteROL neb) (Xopenex® neb): $175/25 nebs*
Anticholinergic only (ipratropIUM neb) (Atrovent® neb): $30/25 nebs*
26
*Current approx. retail costs from Goodrx.com. Actual costs to hospice are per pharmacy contracts and will vary.
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
14
Case: COPD with Fluid Overload
78 year old female with severe COPD and PMH of CHF and CKD 4. Increased wheezing due to decline. Nebs scheduled + PRN not fully effective. Clinically significant lower extremity edema and lung congestion. Hx DM2 – taking metformin and glipizide, and not monitoring glucose.
A) Would an oral steroid be appropriate?
B) Does it matter which one?
C) What about diabetes control?
27
Case: COPD with Fluid Overload
78 year old female with severe COPD and PMH of CHF and CKD 4. Increased wheezing due to decline. Nebs scheduled + PRN not fully effective. Clinically significant lower extremity edema and lung congestion. Hx DM2 – taking metformin and glipizide, and not monitoring glucose.
A) Would an oral steroid be appropriate?
Possible pros: improved breathing control (due to reduced inflammation in thelungs)
Possible cons: increased edema, higher blood glucose, insomnia/anxiety if takentoo late in the day, multiple risks with long-term use
28
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
15
Case: COPD with Fluid Overload
78 year old female with severe COPD and PMH of CHF and CKD 4. Increased wheezing due to decline. Nebs scheduled + PRN not fully effective. Clinically significant lower extremity edema and lung congestion. Hx DM2 – taking metformin and glipizide, and not monitoring glucose.
B) Does it matter which oral steroid?
Dexamethasone: glucocorticoid – no increased edema
Prednisone: mineralocorticoid – increases edema
Methylprednisolone: mineralocorticoid – increases edema
All can increase blood glucose (but usually not a deterrent)
All can increase stimulation/anxiety/insomnia (so take in the morning)
29
Case: COPD with Fluid Overload
78 year old female with severe COPD and PMH of CHF and CKD 4. Increased wheezing due to decline. Nebs scheduled + PRN not fully effective. Clinically significant lower extremity edema and lung congestion. Hx DM2 – taking metformin and glipizide, and not monitoring glucose.
C) What about glucose control?
Small and/or temporary steroid doses used to help with breathing do not typicallyraise glucose enough to make a clinically significant impact. Can increase DM2meds if needed.
If not monitoring, it is likely not a major problem, or not a goal of care to manageDM2
Glucose ranges up to low-mid 300s typically acceptable on hospice as long as noclinically significant symptoms.2,3 More concerned about hypoglycemia (morereadily symptomatic) rather than hyperglycemia. 30
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
16
What Else Will Work Well for Many Patients?
If already taking nebs scheduled + PRN, + oral steroid (or they are contraindicated)…
Guaifenesin (Robitussin, Mucinex®) or… water!
Saline nebs
Cough suppressants (dextromethorphan,promethazine+codeine, others)
Opioids (morphine, others)
Anxiolytics (lorazepam, others)
Oxygen
Non-pharmacologic therapies 31
What Else Will Work Well for Many Patients?
If already taking nebs scheduled + PRN, + oral steroid (or they are contraindicated)…
Guaifenesin (Robitussin, Mucinex®) or… water!
Use in order to wet, loosen or thin out sticky & tenacious secretions
Need high doses (1200-2400 mg/day) – don’t bother with 100-200mg doses
Water as effective or more effective than guaifenesin – drink up (iftolerated)
Inexpensive
Avoid when patient too weak to expectorate (could worsen symptoms)32
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
17
What Else Will Work Well for Many Patients?
Saline nebs
Use in order to wet, loosen, or thin out sticky & tenacioussecretions
Use in addition to or instead of guaifenesin/water
Inexpensive
Avoid when patient too weak to expectorate (could worsensymptoms)
33
If already taking nebs scheduled + PRN, + oral steroid (or they are contraindicated)…
What Else Will Work Well for Many Patients?
If already taking nebs scheduled + PRN, + oral steroid (or they are contraindicated)…
Cough Suppressants
Possible negative: prohibits patient from “getting the gunk out”
Focus usage at night, when coughing interferes with sleep (but ok during theday)
Good for when patient too weak to expectorate (can use with anti-secretory)
Cost effective: dextromethorphan, hydrocodone+homatropine,promethazine+codeine, benzonatate, guaifenesin combo products (+codeine,+dextromethorphan)
34
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
18
What Else Will Work Well for Many Patients?
Opioids
Morphine is the gold standard (due to extensive studies), but any mu receptoragonist (aka opioid) will work, including methadone
Reduces oxygen demand and respiratory drive in the brain stem (respiratorycenter) – basically, is “beneficial” respiratory depression
Natural cough suppressant
No clinically significant negative impact on respiratory function in COPD –patients usually benefit4
Cost effective opioids: morphine IR tabs, morphine concentrate, oxycodone IRtabs, methadone (others high cost or costs are rising) 35
If already taking nebs scheduled + PRN, + oral steroid (or they are contraindicated)…
What Else Will Work Well for Many Patients?
Anxiolytics
These DO NOT directly reduce oxygen demand or respiratory drive via thebrain stem like opioids do
Benefits/effects come from cutting the anxiety-dyspnea cycle (reduceanxietyreduce dyspnea)
If no anxiety, probably will not help SOB
Cost-effective and “safer” benzodiazepines: lorazepam, clonazepam
Other cost-effective anxiolytics: trazodone, mirtazapine, buspirone36
If already taking nebs scheduled + PRN, + oral steroid (or they are contraindicated)…
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
19
What Else Will Work Well for Many Patients?
Oxygen
Titrate to 88-92%5
37
If already taking nebs scheduled + PRN, + oral steroid (or they are contraindicated)…
What Else Will Work Well for Many Patients?
Non-Pharmacologic
Fans for COPD patients: effective for breathlessness6
Pursed-lip breathing
Cold water to face
Energy conservation
Relaxation techniques
38
If already taking nebs scheduled + PRN, + oral steroid (or they are contraindicated)…
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
20
Case: COPD Exacerbation, on Basic Regimen
78 year old female with severe COPD and PMH of CHF and CKD. Increased wet cough/congestion with increased SOB. New crackles in lung bases heard. No fever, but increased exposure to air pollutants over the past few days. Edema controlled. RR elevated. O2 saturation 92% on 3 L/min. Albuterol/ipratropium scheduled + PRN being used frequently. Dexamethasone therapy was started yesterday. Tolerating therapies well, but needs additional symptom control. On fluid restrictions.
A) What other therapies can we start for increased cough/congestion and SOB?
39
Case: COPD Exacerbation, on Basic Regimen
40
Guaifenesin (Robitussin®, Mucinex®) or… water! YES! High doseMucinex® tabs ok (avoid liquid since fluid-restricted)
Saline nebs –eh, already using a lot of nebs
Cough suppressants –can use, but avoid when greater goal is toexpectorate
Opioids (morphine, others) YES! Select based on pt-specific factors
Anxiolytics (lorazepam, others) –only if anxiety is contributing to SOB
Oxygen –not hypoxemic, can keep current rate
Pursed lip, fan/airflow, cold water, relaxation YES!
Remember: If already taking nebs scheduled + PRN, + oral steroid (or they are contraindicated)…
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
21
What About Antibiotics (Abx)?
For Acute Respiratory Symptoms (COPD Exacerbation):
First, consider viral infection!
COPD exacerbations are mainly triggered by viral infections5
Abx will not work
Second, consider environmental triggers
Common
Air pollution, allergens, temperature changes
41
What About Antibiotics (Abx)?
For Acute Respiratory Symptoms (COPD Exacerbation):
For hospice: might try IF patient meets certain criteria (see nextslide)
Use of abx remains controversial5
Abx selection based on many factors and not part of this presentationscope
not always azithromycin!
42
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
22
Criteria for Antibiotic Use in Acute COPD Exacerbation5
When there is increased sputum purulence AND 1+ other CardinalSymptom
Other Cardinal Symptoms: increased dyspnea, increased sputumvolume
(Require mechanical ventilation – not generally applicable tohospice)
43
What About Antibiotics (Abx)?
For Chronic Respiratory Symptoms (Prevention of COPD Exacerbations):
For hospice: benefit does not seem to outweigh potential risks
Data for azithromycin only (do not use other abx for prevention):7
Only 0.35 fewer exacerbations over 12 months vs placebo (1.48 vs 1.83exacerbations per person per year)7
Dyspnea scores improved by 2 pts vs placebo (4 points considered‘clinically significant’)7
Risks: abx resistance,7,8 hearing loss (sometimes permanent),arrhythmias7
44
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
23
2+ COPD exacerbations in the previous year [most hospice COPD pts]
QTc < 450 msec on ECG, and not taking other QTc-prolonging drugs(n/a on hospice)
No cardiovascular disease (heart failure, coronary artery disease,peripheral vascular disease, or cerebrovascular disease) [good luck!]
No hearing loss on formal audiology testing (n/a on hospice)
A sputum culture negative for mycobacteria (n/a on hospice)
Heart rate < 100 / min
ALT and AST < 3 times normal (n/a on hospice)45
Criteria for Antibiotic Use in Prevention of COPD Exacerbations7,9
Continue Roflumilast (Daliresp®)?
46
NO!
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
24
Continue Roflumilast (Daliresp®)?
47
“But why not just keep them on it, if they insist, even if itmay not prevent any exacerbations/hospitalizations whileon hospice?”
Retail cost (Goodrx.com): approx. $210/15 days
Potential adverse effects11 – weight loss, diarrhea, nausea,headache
Drug Interactions (mainly via CYP3A4 – lots of medications)11
An extra pill to take
Continue Theophylline?
48
No – discontinue (consider taper off) maintenancetherapy
Do not add for exacerbations5
Increased adverse effects and risks of toxicity (dose-dependent) Palpitations/arrhythmias (can be fatal), seizures, headache,
insomnia, nausea, heartburn
Narrow therapeutic & toxic serum level thresholds (easilybecomes toxic, or even non-therapeutic)
Benefit occurs only when near-toxic doses are given5
Many drug interactions (warfarin, digoxin, etc)
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
25
Case: COPD New Admission, Hesitant about Nebs
“But I don’t WANT to stop these inhalers, they’re my lungs!”
49
Case: COPD New Admission, Hesitant about Nebs
“But I don’t WANT to stop these inhalers, they’re my lungs!”
Try alternating inhaler and neb therapies by slowly reducing #puffs and/orfrequency of inhaler doses, while slowly increasing frequency of nebtreatments over time
50
Example: Spiriva® every other day and Symbicort® once daily, and DuoNeb® once or twice daily, working up to goal DuoNeb® scheduled TID-QID frequency (add oral steroid if needed)
Follow Up Question: Why don’t we really need to worry aboutpatient getting duplicate or over-exposure of inhaled therapies?
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
26
Proper Inhaler Technique – Overview12
There are so many inhalers – each with own directions
Generics may not operate the same way as Brands
Look up specific usage/cleaning/storage directions foreach inhaler
Use teach-back method to ensure patient can adequatelyuse
51
Proper Inhaler Technique – Education Points13
Questions Patients Should Ask: Do I need to shake my inhaler before using it?
Do I need to "prime" my inhaler with test sprays? If so, how andwhen?
Should I clean my inhaler? If so, with what (e.g., dry cloth, dampcloth, running water)?
Use bronchodilators first (relax and open airways foradditional medication) “ROL” medications – albuterol, salmeterol, etc. Often found
in combination with anticholinergic and/or steroid
Rinse mouth with water and spit out after steroid inhaler
52
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
2/7/2019
27
Proper Inhaler Technique – Education Points13
53
Metered-dose Inhalers (MDI):
Dry-powder Inhalers (DPI):
Soft-mist Inhalers:
Shake most before use Do not shake Do not shake
Prime most before first use No need to prime Prime before first use
Slow deep breath Quick deep breath Slow deep breath
General Usage Techniques (does not apply to every/all inhaler in each category):
Summary (satisfying the objectives)
1. Most patients will respond well to scheduled + PRNalbuterol/ipratropium nebs +/- prednisone or dexamethasone. Otherdrug and non-drug therapies can be added depending on symptom typeand based on patient-specific factors.
2. Oral therapies approved for use in COPD are not always safe oreffective in end-stage patients on hospice. Use abx judiciously; dalirespis usually unnecessary; avoid theophylline.
3. Alternating and increasing neb treatments, while slowly reducinginhaler use can help patients wean off expensive and difficult to useinhalers. Ensure proper inhaler technique if patients continue theirinhalers.
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The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
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Thank you!
Questions/Discussion
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References1. Barrons R, Pegram A, Borries A. Inhaler device selection: special considerations in
elderly patients with chronic obstructive pulmonary disease. Am J Health Syst Pharm2011;68:1221-32.
2. King EJ, Haboubi H, Evans D, et al. The management of diabetes in terminal illnessrelated to cancer. QJM. 2012; 105:3-9.
3. McCoubrie R, Jeffrey D, Paton C, Dawes L. Managing diabetes mellitus in patientswith advanced cancer: a case note audit and guidelines. Eur J Cancer Care. 2005;14(3):244-8.
4. Jennings AL, Davies AN, Higgins JP, et al. A systematic review of the use of opioids inthe management of dyspnoea. (review) Thorax 2002;57(11):939-44
5. Global Strategy for Diagnosis, Management and Prevention of COPD, Global Initiativefor Chronic Obstructive Lung Disease (GOLD) 2018. http://www.goldcopd.org.
6. Galbraith, Sarah et al. Does the Use of a Handheld Fan Improve Chronic Dyspnea? ARandomized, Controlled, Crossover Trial. Journal of Pain and Symptom Management.2010;39(5):831 – 838. DOI: https://doi.org/10.1016/j.jpainsymman.2009.09.024
7. Albert RK, et al. for the COPD Clinical Research Network. Azithromycin forPrevention of Exacerbations of COPD. N Engl J Med 2011; 365:689-698. DOI:10.1056/NEJMoa1104623
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The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.
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References
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8. Himanshu Desai, Sandra Richter, Gary Doern, et al. Antibiotic Resistance in Sputum Isolatesof Streptococcus pneumoniae in Chronic Obstructive Pulmonary Disease is Related toAntibiotic Exposure, COPD. Journal of Chronic Obstructive Pulmonary Disease. 2010;7(5): 337-344. DOI: 10.3109/15412555.2010.510162
9. PulmCC Inc. Antibiotics (azithromycin) to prevent COPD exacerbations (Review). OnlineArticle. 2013. URL: https://pulmccm.org/review-articles/antibiotics-azithromycin-to-prevent-copd-exacerbations-review-nejm/
10. Daliresp Efficacy. Daliresphcp.com. URL: https://www.daliresphcp.com/daliresp-efficacy.html.html. Accessed 2/3/2019.
11. Lexicomp Online, Lexi-Drugs Online, Hudson, Ohio: Lexi-Comp, Inc.; 2019; February 3, 2019.
12. Clinical Resource, Correct Use of Inhalers. Pharmacist’s Letter/Prescriber’s Letter. January2017.
13. Tips for Correct Use of Inhalers. Pharmacist’s Letter. 2016; Detail-Document#: 330106.https://pharmacist.therapeuticresearch.com/Content/Segments/PRL/2017/Jan/Tips-for-Correct-Use-of-Inhalers-10563
The material in this presentation is for informational and educational purposes only and is not a substitute for medical advice, diagnosis, or treatment provided by a qualified health care provider. All information contained in this presentation is protected by copyright and remains the property of ProCare HospiceCare. All rights are reserved.