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Smoking Cessation and Chronic Obstructive Pulmonary Disease (COPD) Management
Stephanie Cox, PharmD, PGY2 Ambulatory Care ResidentRachel Lee, PharmD, PGY1 Pharmacy ResidentShelby Williams, PharmD, PGY1 Pharmacy Resident
May 29, 2015
VETERANS HEALTH ADMINISTRATION 2
Disclosure Statement
• Disclosure statement: these individuals have the following to disclose concerning possible financial or personal relationships with commercial entities (or their competitors) that may be referenced in this presentation
- Resident: Stephanie Cox, Pharm.D. – nothing to disclose
- Resident: Rachel Lee, Pharm.D. - nothing to disclose
- Resident: Shelby Williams, Pharm.D. – nothing to disclose
VETERANS HEALTH ADMINISTRATION 3
Objectives
• Explain non-pharmacological and pharmacological treatment options for smoking cessation
• Discuss current chronic obstructive pulmonary disease (COPD) guidelines
• Demonstrate proper inhaler administration technique
• Discuss counseling guidelines for the commonly used inhalers for COPD treatment
Smoking Cessation
VETERANS HEALTH ADMINISTRATION 5
Smoking Rates
• About 1 in 5 American adults smoke cigarettes (17.8%)
• Smoking rate is higher among some Veterans than the general population
• Annual smoking-attributable cost in the U.S. for direct medical care between 2009-2012 was $132.5-175.9 billion
Smoking-Attributable Morbidity, Mortality, and Economic Costs. http://www.surgeongeneral.gov/library/reports/50-years-of-progress/sgr50-chap-12.pdf. Accessed May 15, 2015. Brown, DW. J Gen Intern Med 25(2): 147-9.
VETERANS HEALTH ADMINISTRATION 6
Consequences of Smoking
• Leading preventable cause of death – accounts for 1 of every 5 deaths
• COPD is about 4 times more prevalent among Veterans than the general population
CDC. Annual Deaths Attributable to Cigarette Smoking—United States. http://www.cdc.gov/tobacco/data_statistics/tables/health/attrdeaths/index.htm. Accessed May 2015.COPD: Challenges and Opportunities for Federal Medicine. COPD Prevalence among Veterans Related to High Smoking Rates. U.S. Medicine.
VETERANS HEALTH ADMINISTRATION 7
COPD Statistics and Prevention
• About 12 million Americans have COPD and another 12 million may be undiagnosed
• In 2010, the cost of COPD in the U.S. was $50 billion
• COPD has a major negative impact on quality of life
• 75% of COPD cases are attributable to cigarette smoking, therefore must focus on prevention– Reduce or eliminate smoking initiation by young adults– Encourage tobacco cessation among current smokers
Public Health Strategic Framework for COPD Prevention. www.cdc.gov/copd/pdfs/Framework_for_COPD_Prevention.pdfClinicoecon Outcomes Res. 2013; 5: 235–245.
VETERANS HEALTH ADMINISTRATION 8
Smoking Cessation Problems
• Chronic disease – requires repeated intervention and multiple attempts to quit
• Many patients try to quit smoking without counseling/pharmacotherapy– Most are unsuccessful– Encourage patients to use these to improve success
• Physicians, pharmacists, and nurses are in a great position to intervene during patient care visits– Physician’s advice is an important motivator
Treating Tobacco Use and Dependence. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/index.html.
VETERANS HEALTH ADMINISTRATION 9
Smoking Cessation Options
• Intervention by physicians– Provide a brief period of counseling (three minutes or less) – Common approach to effective intervention
• Counseling– Group or individual– Repeated contacts over at least four weeks
• Pharmacotherapy
• Both counseling and pharmacotherapy are each effective, but the two in combination achieve the highest rates of smoking cessation
Treating Tobacco Use and Dependence. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/index.html.N Engl J Med 2002; 346:506-512.
VETERANS HEALTH ADMINISTRATION 10
Assessment during Patient Visits - NEJM
Ask patient whether he or she smokes
If the answer is “Yes”
Offer personalized advice about stopping smoking (e.g. “Quitting smoking is the most important
action you can take to stay healthy”)
Determine whether the patient is interested in quitting at this time
Rigotti, NA. N Engl J Med 2002; 346:506-512.
VETERANS HEALTH ADMINISTRATION 11
Assessment during Patient Visits - NEJM
If the answer is “Yes, in the next 30 days”
• Ask smoker to set a quit date
• Assess prior efforts:– “What have you tried?”– “What worked?”– “What didn’t work?”
• Help smoker make a plan:– Offer pharmacotherapy– Offer behavioral support
• Referral to counseling program (telephone or in person)• On-line resources
• Express confidence in the smoker’s ability to quit
Rigotti, NA. N Engl J Med 2002; 346:506-512.
VETERANS HEALTH ADMINISTRATION 12
Assessment during Patient Visits - NEJMIf the answer is “Yes, but not now”
• Identify and address barriers to quitting:– Nicotine dependence– Fear of failure– Lack of social support (friends and family smoke)– Little self-confidence in ability to stop smoking– Concern about weight gain– Depression– Substance abuse
• Identify reasons to quit:– Health related– Other
• Ask patient to set a quitting date
Rigotti, NA. N Engl J Med 2002; 346:506-512.
VETERANS HEALTH ADMINISTRATION 13
Assessment during Patient Visits - NEJM
If the answer is “No”
• Use motivational strategies:– Avoid argument– Acknowledge smoker’s ambivalence about quitting– Elicit smoker’s view of the pros and cons of smoking and smoking
cessation– Correct smoker’s misconceptions about health risks of smoking and
the process of quitting smoking
• Discuss risks of passive smoking for family and friends• Offer to help smoker when he or she is ready to quit
Rigotti, NA. N Engl J Med 2002; 346:506-512.
VETERANS HEALTH ADMINISTRATION 14
Pharmacotherapy Options
• Nicotine replacement therapy (NRT)– Temporarily replaces some of the nicotine from cigarettes to reduce
motivation to smoke and nicotine withdrawal symptoms– Examples: Patch, gum, lozenge
• Bupropion– May block nicotine effects, relieving withdrawal and reducing
depressed mood
• Varenicline (Chantix)– Helps by maintaining moderate levels of dopamine to counteract
withdrawal symptoms and reducing smoking satisfaction
Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
VETERANS HEALTH ADMINISTRATION 15
Treatment Efficacy
• Dual NRT (more effective than single NRT)– Nicotine patch + nicotine gum– Nicotine patch + nicotine lozenge
• Nicotine patch + bupropion SR
• Varenicline (Chantix)
• All 3 options are proven effective options
Treating Tobacco Use and Dependence. April 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update/index.html.Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
VETERANS HEALTH ADMINISTRATION 16
Nicotine Patch• Dosing: number of cigarettes smoked per day
• Pharmacotherapy pearls:– Apply a new patch every 24 hours
• If nightmares occur, may remove the patch before bed each night– Takes a few hours to reach peak levels
• Side effects: skin sensitivity and irritation (usually mild)
# of Cigarettes/day Patch Dosing> 10 cigarettes/day 21 mg/day x 4 weeks, then
14 mg/day x 2 weeks, then 7 mg/day x 2 weeks
≤ 10 cigarettes/day OR < 45 kg body weight
14 mg/day x 6 weeks, then7 mg/day x 2 weeks
Nicoderm CQ [package insert]. GlaxoSmithKline. Moon Township, PA. 2014.Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
VETERANS HEALTH ADMINISTRATION 17
Nicotine Gum
• Dosing: number of cigarettes smoked each day
• Pharmacotherapy pearl: “chew and park” for 30 minutes• Side effects: hiccoughs, GI disturbances, jaw pain, and orodental problems
# of Cigarettes/day Dose≥ 25 cigarettes/day 4 mg every 1-2 hours for 6 weeks, then
gradually reduce over an additional 6 weeksMax: 24 pieces/day
< 25 cigarettes/day 2 mg every 1-2 hours for 6 weeks, then gradually reduce over an additional 6 weeksMax: 24 pieces/day
Sunmark Nicotine [package insert]. GlaxoSmithKline. Moon Township, PA. 2014. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
VETERANS HEALTH ADMINISTRATION 18
Nicotine Lozenge
• Dosing: timing of first cigarette of day
• Pharmacotherapy pearl: dissolve over 30 minutes• Side effects: hiccoughs, burning and smarting sensation in the mouth, sore
throat, coughing, dry lips and mouth ulcers
Timing DoseFirst cigarette < 30 minutes after awakening
4 mg every 1-2 hours for 6 weeks, then gradually reduced over an additional 6 weeksMax: 5 lozenges every 6 hours or 20 per day
First cigarette ≥ 30 minutes after awakening
2 mg every 1-2 hours for 6 weeks, then gradually reduced over an additional 6 weeksMax: 5 lozenges every 6 hours or 20 per day
Nicorette – nicotine lozenge. [package insert]. GlaxoSmithKline. Moon Township, PA. 2014. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
VETERANS HEALTH ADMINISTRATION 19
Bupropion SR
• Dosing: 150 mg/day x3 days, then 150 mg twice daily for at least 12 weeks
• Pharmacotherapy pearls:– Usually started 5-7 days prior to patients quit date– May blunt weight gain associated with smoking cessation
• Side effects:– Insomnia (30-40%)– Dry mouth (10%)– Nausea (< 10%)– Seizures (less common)
• Use caution in patients with a history of seizures
Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
VETERANS HEALTH ADMINISTRATION 20
Varenicline (Chantix)
• Restricted to CARP
• Dosing: – Week 1 (titration)
• Days 1-3: 0.5 mg tablet every day• Days 4-7: 0.5 mg tablet twice daily
– Weeks 2-12• 1 mg tablet twice daily
• Side effects: nausea (30%), abnormal dreams, headache
• Cautions:– Neuropsychiatric symptoms– Seizures– Increased intoxicating effects of alcohol– Cardiovascular events (patients with known cardiovascular history)
Chantix [package insert]. Pfizer Labs. New York, NY. Feb 2015.Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
VETERANS HEALTH ADMINISTRATION 21
Recommendations
• Spend the extra few minutes to discuss smoking cessation
• If patients are ready, refer for counseling or the smoking cessation class
• Offer pharmacotherapy, including dual NRT or nicotine patch plus bupropion SR – use the clinical reminder to order medications
• Ensure patients are receiving the correct amounts of pharmacotherapy
COPD GuidelinesGlobal Initiative for Chronic Obstructive Lung Disease (GOLD) 2015
22
VETERANS HEALTH ADMINISTRATION 23
Diagnosing COPD
• Indicators of COPD– Dyspnea, chronic cough, chronic sputum production,
family history– Exposure to risk factors
• Clinical diagnosis– Spirometry • Post-bronchodilator FEV1/FVC <0.70
Global initiative for chronic obstructive lung disease (GOLD). 2015. COPD, INC.
VETERANS HEALTH ADMINISTRATION 24
Assessment of COPD
• Symptoms– COPD Assessment Test (CAT)– Modified British Medical Research Council (mMRC) scale
• Exacerbation
Symptoms Score
Less symptoms mMRC 0-1 or CAT <10
More symptoms mMRC ≥ 2 or CAT ≥10
risk # exacerbation/ year or hospitalization
Low ≤ 1 or no hospitalization for exacerbation
High ≥ 2 and ≥ 1 hospitalization for exacerbation
VETERANS HEALTH ADMINISTRATION 25
Assessment of COPD
• Severity level
Gold level Severity FEV1 Predicted1 Mild ≥ 80%2 Moderate 50-79%3 Severe 30-49%4 Very severe <30%
VETERANS HEALTH ADMINISTRATION 26
Combined Assessment
VETERANS HEALTH ADMINISTRATION 27
Pharmacologic Treatments
Broadwith, P. New respiratory drugs neck and neck. Royal Chemistry Society. 2015
VETERANS HEALTH ADMINISTRATION
Beta 2-Agonists
• Mechanism of Action (MOA): Binds to beta-2 receptors on the bronchial smooth muscle to induce bronchodilation
• Adverse effects: cardiac rhythm disturbance and tremor
Generic Brand Formulations DOA (hours)
Short actingalbuterol Proventil HFA Inhaler, Neb, tablet 4-6levalbuterol (NF) Xopenex Inhaler, Neb 6-8
Long acting formoterol (R) Preforomist Inhaler, Neb 12salmeterol (NF) Serevent Inhaler 12arformoterol (NF) Brovana Neb 12
Global initiative for chronic obstructive lung disease (GOLD). 2015. COPD, INC.
VETERANS HEALTH ADMINISTRATION 29
Anticholinergics
• MOA: Blocks acetylcholine from binding muscarinic receptors to promote bronchodilation
• Adverse effects: dry mouth and bitter metallic taste• Avoid combination of short and long-acting anticholinergics
therapy
Generic Brand Formulations DOA (hours)
Short acting ipratropium Atrovent HFA Inhaler, Neb 6-8
Long actingtiotropium (R) Spiriva Inhaler 24
aclidinium (NF) Tudorza Inhaler 12
VETERANS HEALTH ADMINISTRATION 30
Inhaled Corticosteroid
• MOA: anti-inflammatory and relieves muscle spasm
• Adverse effects: oral candidiasis and hoarse voice
Generic Brand Formulations
beclomethasone (NF) QVAR Inhaler, Neb
budesonide (NF) Pulmicort Inhaler, Neb
fluticasone (NF) Flovent Inhaler
VETERANS HEALTH ADMINISTRATION 31
Phosphodiesterase-4 Inhibitors
• MOA: Anti-inflammatory
• Adverse effects: nausea, reduce appetite, headache, sleep disturbance and abdominal pain
• Criteria for Use – Requires a Non-Formulary consult
Generic Brand Formulation DOA (hours)
roflumilast (NF) Daliresp Oral pill 24
VETERANS HEALTH ADMINISTRATION 32
Methylxanthines (Theophylline)
• MOA: non-selective phosphodiesterase inhibitor to promote bronchodilation
• Therapeutic range for adults: 5-15 mcg/mL– Dose adjustments based on drug levels
• Adverse effects: arrhythmias, convulsion, insomnia, headaches
• Less effective and less well tolerated
• Not recommended
VETERANS HEALTH ADMINISTRATION 33
Combination Products
Generic Brand Formulation
Short acting beta 2-agonist + short acting anticholinergic albuterol + ipratropium Combivent Inhaler
Long acting beta 2-agonist + inhaled corticosteroid formoterol + budesonide (R) Symbicort Inhaler
formoterol + mometasone (NF) Dulera Inhaler
salmeterol + fluticasone (NF) Advair Inhaler
VETERANS HEALTH ADMINISTRATION 34
COPD Management
VETERANS HEALTH ADMINISTRATION
Management- Group A
• Low risk, less symptoms
1st line Alternative Other SA anticholinergic PRN SA Beta 2-agonist + SA
anticholinergicTheophylline
SA beta 2-agonist PRN LA anticholinergic
LA beta 2-agonist
SA: Short actingLA: long acting
VETERANS HEALTH ADMINISTRATION 36
Management- Group B
• Low risk, more symptoms
1st line Alternative Other LA anticholinergic LA anticholinergic + LA beta 2-agonist SA anticholinergic
And/ORSA beta 2-agonist
LA beta 2-agonist Theophylline
SA: Short actingLA: long acting
VETERANS HEALTH ADMINISTRATION 37
Management- Group C
• High risk, less symptoms
SA: Short acting LA: Long actingICS: Inhaled corticosteroid PDE-4 : Phosphodiesterase-4
1st line Alternative Others
ICS + LA anticholinergic
LA anticholinergic + LA beta 2-agonist SA anticholinergic And/OR
SA beta 2-agonist
ICA + LA beta agonist LA anticholinergic + PDE-4 Inhibitor Theophylline
LA beta 2-agonist + PDE-4 Inhibitor
VETERANS HEALTH ADMINISTRATION 38
Management- Group D
• High risk, more symptoms1st line Alternative Other
ICS + LA anticholinergic + LA beta 2-agonist
ICS + LA beta 2-agonist + PDE-4 inhibitor
SA anticholinergic And/OR
SA beta 2-agonist
LA anticholinergic + LA beta 2-agonist
Theophylline
LA anticholinergic + PDE-4 inhibitor
SA: Short acting LA: Long actingICS: Inhaled corticosteroid PDE-4 : Phosphodiesterase-4
Administration Technique and Counseling Pearls for COPD Inhalers
39
VETERANS HEALTH ADMINISTRATION 40
Background
At least 50% of patients who are prescribed inhalers may be using them incorrectly
Health care providers may have a knowledge gap when it comes to the correct use of different
inhaler devices
Suboptimal control of COPD
Pharmacist’s Letter 2014; 30(2):300206
=
&/or
VETERANS HEALTH ADMINISTRATION 41
Various Devices
• Metered-dose inhalers (MDI)–May require priming/shaking prior to use–Require good hand-breath coordination
• Dry-powder inhalers (DPIs)–Breath-activated
• Soft-mist inhalers
Pharmacist’s Letter 2014; 30(2):300206
VETERANS HEALTH ADMINISTRATION 42
Metered-Dose Inhalers (MDIs)
Images: Google Search “metered-dose inhalers”
VETERANS HEALTH ADMINISTRATION 43
Available MDI Agents
• Short acting beta-2 agonists– albuterol 90 mcg
• Dosing: 1-2 inhalations QID and/or PRN
– levalbuterol 45mcg (NF)• Dosing: 1-2 inhalations QID and/or PRN
• Short acting anticholinergic– ipratropium 21 mcg
• Dosing: 1-2 inhalations QID and/or PRN
• Long-acting beta 2 agonist/corticosteroid– budesonide/formoterol 160/4.5 mcg (R)
• Dosing: 2 inhalations BID
Pharmacist’s Letter 2014; 30(2):300206Pharmacist’s Letter 2014; 30(10):3010112014 VA/DoD COPD Clinical Practice GuidelinesQID = Four times daily; PRN = as needed; BID = twice daily
VETERANS HEALTH ADMINISTRATION 44
MDI Agents: Short Acting Bronchodilators
Generic Brand Shake before use Priming Dose Counter
albuterol
ProAir HFA Yes Before 1st useNot used >14 days 3 sprays Yes
Proventil HFA Yes Before 1st useNot used >14 days 4 sprays No
Ventolin HFA(NF) Yes
Before 1st useNot used for >14 days
Inhaler dropped4 sprays Yes
levalbuterol (NF) Xopenex HFA Yes Before 1st use
Not used for >3 days 4 sprays Yes
ipratropium Atrovent HFA No Before 1st useNot used >3 days 2 sprays Yes
Pharmacist’s Letter 2014; 30(2):300206Pharmacist’s Letter 2014; 30(10):301011
Formulary NF = Non-formulary
Clinical pearls: -Beyond Use Date (BUD) = manufacturer’s expiration date on the packaging -Require at least weekly cleaning of device
VETERANS HEALTH ADMINISTRATION 45
MDI Agents: Long Acting Bronchodilators
Generic Brand Shake before use Priming Dose Counter
budesonide/formoterol
(R)Symbicort Yes
Before 1st useNot used for >3 days
Inhaler dropped2 sprays Yes
Clinical pearls: -After use of the inhaler, patient should rinse mouth with water and spit out solution-BUD = 3 months after removal from foil pouch
Pharmacist’s Letter 2014; 30(2):300206Pharmacist’s Letter 2014; 30(10):301011
VETERANS HEALTH ADMINISTRATION 46
MDI Agents: General Steps for Use
• Remove cap• Look inside the mouthpiece for foreign objects• Shake the inhaler well, if necessary• Breathe out fully through the mouth, away from the inhaler
• Press the canister down while inhaling deeply and slowly through the mouth
• Hold breath for as long as comfortably possible (~10 seconds)• Breathe out slowly• Wait 30-60 seconds before repeating
Spacer/no spacer
Pharmacist’s Letter 2014; 30(2):300206Pharmacist’s Letter 2014; 30(10):301011
Open/closed mouth
VETERANS HEALTH ADMINISTRATION 47
MDI: General Steps for Use (Without a Spacer)
CLOSED MOUTH• Remove cap• Check the mouthpiece for foreign objects• Shake the inhaler, if necessary• Breathe out fully through the mouth, away from the inhaler• Place the mouthpiece in mouth and tighten lips• Press the canister down while inhaling deeply and slowly through the
mouth• Remove inhaler from the mouth• Hold breath for as long as comfortably possible (~10 seconds)• Breathe out slowly• Wait 30-60 seconds before repeating
Pharmacist’s Letter 2014; 30(2):300206 Image: Google search “meter dose inhaler”
VETERANS HEALTH ADMINISTRATION 48
MDI: General Steps for Use (Without a Spacer)
OPEN MOUTH• Remove cap• Check the mouthpiece for foreign objects• Shake the inhaler, if necessary• Breathe out fully through the mouth, away from the inhaler• Place the inhaler two fingers’ width away from the lips• With mouth open and tongue flat, tilt the mouthpiece of the device toward the
upper back of the mouth• Press the canister down while inhaling deeply and slowly through the mouth• Move the mouthpiece away from the mouth• Hold breath for as long as comfortably possible (~10 seconds)• Breathe out slowly• Wait 30-60 seconds before repeating
Pharmacist’s Letter 2014; 30(2):300206 Image: Google search “meter dose inhalers”
VETERANS HEALTH ADMINISTRATION 49
MDI: General Steps for Use (With a Spacer)
• Remove cap• Look inside the mouthpiece for foreign objects• Shake the inhaler well, if necessary• Attach the spacer and the inhaler together, with the inhaler’s canister in a
vertical position• Breathe out fully through the mouth, away from the inhaler• Put the mouthpiece of the spacer between the teeth and tighten lips
around• Press the canister down and inhale deeply and slowly through the mouth• Hold breath for as long as comfortably possible (~10 seconds)• Breathe out slowly• Wait 30-60 seconds before repeating
Pharmacist’s Letter 2014; 30(2):300206 Image: Google search “meter dose inhalers”
VETERANS HEALTH ADMINISTRATION 50
Dry-Powder Inhalers (DPIs)
• Diskus• Ellipta• Aerolizer• Flexhaler• Diskhaler
• HandiHaler• Neohaler• Podhaler• Pressair• Twisthaler
Pharmacist’s Letter 2014; 30(2):300206Images: Google search “dry powder inhalers”
VETERANS HEALTH ADMINISTRATION 51
DPIs: Diskus Agents
• Long acting beta-2 agonist/corticosteroid– fluticasone/salmeterol 250/50 mcg (NF)• 1 inhalation Q12h
• Long-acting beta-2 agonists– salmeterol 50 mcg (NF)• 1 inhalation Q12h
Pharmacist’s Letter 2014; 30(2):300206
VETERANS HEALTH ADMINISTRATION 52
DPIs: Diskus Agents
Generic Brand Shake before use Priming Dose Counterfluticasone/salmeterol
(NF)Advair Diskus No No Yes
Clinical pearls:-Rinse mouth after inhaler use-BUD = 1 month after removal from foil pouch or when dose counter reads “0”-No cleaning required of device
salmeterol(NF) Serevent Diskus No No Yes
Clinical pearl:-BUD = 6 weeks after removal from foil pouch or when dose counter reads “0”-No cleaning required of device
Pharmacist’s Letter 2014; 30(2):300206
VETERANS HEALTH ADMINISTRATION 53
DPIs: DiskusGeneral Steps for use
• Open inhaler using the thumb grip• Hold inhaler flat & level, slide lever from left to right until it
clicks• Breathe out fully through the mouth, away from the inhaler• Put the mouthpiece in the mouth and tighten the lips around it• Inhale quickly and deeply through the mouth• Remove the device from the mouth• Hold the breath as long as comfortably possible (~10 seconds)• Breathe out slowly• Use the thumb grip to close the inhaler
Pharmacist’s Letter 2014; 30(2):300206
VETERANS HEALTH ADMINISTRATION 54
DPIs: Aerolizer Agent
• Long-acting beta-2 agonist (LABA)– formoterol 12mcg (R)
• 1 inhalation twice daily
VETERANS HEALTH ADMINISTRATION 55
DPIs: Aerolizer Agent
Generic Brand Shake before use Priming Dose Counter
formoterol (R) Foradil Aerolizer No No Yes
Clinical pearls:-Do not swallow capsules-BUD = 4 months from date of dispensing-No cleaning required of device
VETERANS HEALTH ADMINISTRATION 56
DPIs: Aerolizer AgentGeneral Steps for Use
• Remove inhaler cover• Hold the base of the inhaler and twist the mouthpiece in the direction of the arrow to open• Remove one capsule from its foil blister• Place capsule in the capsule chamber in the base of the inhaler• Twist the mouthpiece back to close• Hold the inhaler upright and press both buttons on the sides one time, at the same time, then
release them• Breathe out fully through the mouth, away from the inhaler• Tilt head back slightly• Hold inhaler horizontally with the buttons on the sides and place between the lips• Breathe in quickly and deeply through the mouth• Remove the inhaler from the mouth• Hold breath for as long as comfortably possible (~10 seconds), then breathe out slowly• Open the chamber to see if any powder remains in the capsule
– If yes, close the chamber and repeat the steps in bold• Open the mouthpiece, remove the used capsule and discard it• Replace inhaler cover
57
VETERANS HEALTH ADMINISTRATION 58
DPIs: HandiHaler Agents
• Long acting Anticholinergic (LAAC)– tiotropium 18 mcg (R)• 1 capsule daily
Pharmacist’s Letter 2014; 30(2):300206
VETERANS HEALTH ADMINISTRATION 59
Dry-Powder Inhaler (DPI): HandiHaler Agent
Pharmacist’s Letter 2014; 30(2):300206
Generic Brand Shake before use Priming Dose Counter
tiotropium (R) Spiriva HandiHaler No No No
Clinical Pearls:-Do NOT swallow capsule-Clean after each use
Empty the remains of the capsule from the inhaler into the trash; turn the inhaler upside down and tap it firmly yet gently to remove any residue
-Clean as neededOpen the base and rinse the inhaler with warm running water; allow 24 hours to air dry
-BUD = manufacturer’s expiration date on the packaging
VETERANS HEALTH ADMINISTRATION 60
Dry-Powder Inhaler (DPI): HandiHalerGeneral Steps for Use
• Remove the inhaler cap by pressing the piercing button• Pull the lid away from the inhaler to expose the mouthpiece• Expose the center chamber by pulling the mouthpiece up and away from its base• Place one capsule (removed from foil blister) in the center chamber of the inhaler• Close the mouthpiece until it clicks• Continue to hold the inhaler with the mouthpiece pointed up• Press the button on the side once, then release it• Breathe out fully through the mouth, away from the inhaler• Place the inhaler in a horizontal position and place the mouthpiece in the mouth
tightening the lips around it• Breathe in deeply through the mouth• Hold the breath for a few seconds• Remove the mouth piece from the mouth• Repeat the steps in bold a second time• Open the mouthpiece, remove the used capsule and discard it• Close the mouthpiece and cap
Pharmacist’s Letter 2014; 30(2):300206
VETERANS HEALTH ADMINISTRATION 61
Soft-Mist Inhalers
Image: Google search “soft-mist inhalers”
VETERANS HEALTH ADMINISTRATION 62
Soft-Mist Inhaler Agents
• Short acting beta-2 agonist/anticholinergic– ipratropium/albuterol 20/100 mcg• 1 inhalation QID
*Max 6 inhalations/day*• Long acting anticholinergic– tiotropium 2.5mcg (R)• 2 inhalations once daily
*Max 2 inhalations/day*
Pharmacist’s Letter 2014; 30(2):300206Package Insert: Combivent Respimat Inhaler.
VETERANS HEALTH ADMINISTRATION 63
Soft-Mist Inhaler Agents
Generic Brand Shake before use Priming Dose
Counter
albuterol/ipratropium
CombiventRespimat No
Before 1st useNot used for >21 days
Spray inhaler into the air until a visible spray is seen, then spray 3
more timesNo
Not used for >3 days 1 spray
tiotropium(R)
Spiriva Respimat*Currently not
available at the VA*
No
Before 1st useNot used for >21 days
Spray inhaler into the air until a visible spray is seen, then spray 3
more times No
Not used for >3 days 1 spray
Pharmacist’s Letter 2014; 30(2):300206Package Insert: Combivent Respimat Inhaler
Clinical pearls:-Clean weekly (wipe mouthpiece inside/out with damp tissue)-BUD = 3 months after assembly of device
VETERANS HEALTH ADMINISTRATION 64
Soft-Mist Inhaler: Assembly
• Before inital use
Package Insert: Combivent Respimat
VETERANS HEALTH ADMINISTRATION 65
Soft-Mist Inhaler: Assembly
Package Insert: Combivent Respimat
VETERANS HEALTH ADMINISTRATION 66
Soft-Mist Inhaler: Respimat General Steps for Use “TOP”
Hold inhaler uprightTurn the base in the direction of the arrows until it clicks
Flip the cap until it snaps openBreathe out fully through the mouth, away from the inhaler
Put the mouthpiece in the mouth and tighten the lips around the end without covering the air vents
Press the dose release button and inhale deeply and slowly through the mouth
Hold the breath as long as comfortably possible (~10 seconds)
Pharmacist’s Letter 2014; 30(2):300206Package Insert: Combivent
VETERANS HEALTH ADMINISTRATION 67
Quick Reference: Available COPD Inhalers
Drug Delivery Strength Dosing FormularySABAs
albuterollevalbuterol
MDIMDI
90 mcg45 mcg
1-2 inh Q4-6h PRN FormularyNon-formulary
SAMAsipratropium MDI 21 mcg 1-2 inh Q6h Formulary
SAMA/SABAipratropium/albuterol SMI 20/100 mcg 1 inh QID Formulary
LABAsformoterolsalmeterol
DPI (capsule)DPI
12 mcg50 mcg 1 inh BID
RestrictedNon-formulary
LAMAstiotropium
DPI (capsule)SMI
18 mcg2.5 mcg
1 inh (DPI) daily2 inh (SMI) daily
RestrictedComing soon
ICS/LABAsbudesonide/formoterolfluticasone/salmeterol
MDI
DPI
160/4.5 mcg
250/50 mcg
2 inh BID
1 inh BID
Restricted
Non-formulary
2014 VA/DoD COPD Clinical Practice Guidelines.
VETERANS HEALTH ADMINISTRATION 68
Self-Assessment
• Break into groups and demonstrate proper inhaler administration technique with each of the various delivery devices.
Smoking Cessation and Chronic Obstructive Pulmonary Disease (COPD) Management
Stephanie Cox, PharmD – [email protected] Lee, PharmD – [email protected] Williams, PharmD – [email protected]
May 29, 2015