PHRM 571: Ambulatory Care

Asthma & COPD

Jason Isch, PharmD, BCACP

Mallory Carter, PharmD, BCPS

March 13th, 2023

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 St. Joe Clinical Practice
What has been your own “personal” experience with
patients in these disease states?

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 Objectives: Asthma/COPD
• Review the clinical guidelines for asthma and COPD

• Assess a patient’s disease state based on key

factors and “grade” them as necessary

• Discuss findings of primary literature in relation

to a patient case and current recommendations

• Differentiate between various kinds of inhalers

and when each might be appropriate for patients

• Plan out treatment for a patient as they progress

throughout the stages of asthma and COPD

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 Asthma vs. Chronic Obstructive
Pulmonary Disorder (COPD)

How would you describe each of these disease states to a

friend/family member who is not in healthcare?

What are the primary differences in treatment

between these groups?

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 Pharmacotherapy Review
• What are the different “classes” of breathing treatments?
• Nebulizers
• Advantages: minimal technique, any age, mix meds simulataneously
• Disadvantages: time consuming, compressed air, immobile, variability, $
• Ideal Populations: homebound folks, youngest -> oldest populations
• Metered Dose Inhalers
• Advantages: small, portable, quick, less $, spacer availability, high lung DF
• Disadvantages: coordination/dexterity required; most education required
• Ideal Populations: NOT for oldest and youngest kiddos (w/o help)
• Dry Powder Inhalers
• Advantages: breath-actuated/ease of use, no propellants, portable, quick
• Disadvantages: requires high inspiratory flow, not available as rescue
• Ideal Populations: children >5 w/ cognitive ability, and not late-stage COPD

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 Asthma Guidelines – GINA 2023
• What are some key points you remember from IPT?

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Asthma Guidelines – GINA 2023

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Assessment

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 Patient Case #1: Asthma
David Brooks is a 34 YOM who suffers from asthma presenting to your
clinic. He is currently being managed on a Ventolin inhaler that he uses
as needed. He states that he uses his inhaler a couple times a week
and it helps his symptoms, and his exacerbations are mild. He states
that has been using this regimen as long as he remembers.

Do you have any concerns with DB's treatment?

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 SMART Trial (Where It All Began)
• What was the bottom line?
• Monotherapy LABAs can KILL people! (NNH = 8)
• What were some of the other important details?

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 Novel START
• What was the bottom line?
• ICS/formoterol PRN noninferior to budesonide maintenance
• What were some of the other important details?

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 SYGMA-1 and SYGMA-2 Trials
• What was the bottom line?
• ICS/formoterol PRN noninferior to budesonide maintenance
• What were some of the other important details?

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 Patient Case #2: Asthma
Dr. Smith says she heard that the new preferred reliever contained an
inhaled corticosteroid and would like to use the combination product
Breo (fluticasone-vilanterol).

Would this be an appropriate relief inhaler?

What if the inhaler was Dulera (mometasone-formoterol)?

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 Patient Case #3: Asthma
Elmer Fud is 57 YOM who has asthma and has been experiencing
several exacerbations every year. His current therapy includes
Symbicort 160/4.5mcg BID that he takes for maintenance therapy and
as needed for rescue situations. He is wondering if he is on the best
therapy to prevent exacerbations and is willing to try anything to
manage his asthma.

What recommendations would you make for Elmer?

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 PrimoTinA-Asthma and CAPTAIN
• What was the bottom line?
• LAMA may have usefulness in severely uncontrolled asthma
• CAPTAIN - Triple therapy once daily?

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Asthma Action Plan

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 COPD Guidelines – GOLD 2024
• What are some key points you remember from IPT?

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Clinical Presentation and Diagnosis

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Clinical Presentation and Diagnosis

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COPD Guidelines – GOLD 2024

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COPD Guidelines – GOLD 2024

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 Patient Case #1: COPD
Bugs Bunny is a 65-year-old male with newly diagnosed COPD and is
staged in Grade 2 (FEV1 55%) and class A. His doctor currently has
him on albuterol/ipratropium (Combivent Respimat) as needed for
difficulty breathing, but he is not on any other medications. He quit
smoking 20 years ago and has made a lot of life changes.

Bugs wants to know if any other medications can help prevent his
COPD from worsening. Are there any options?

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 UPLIFT Trial
• What was the bottom line?
• LABA (Tiotropium) improved factors but
did not reduce the decline of FEV1
• What were some of the other important details?

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 POET/INVIGORATE Trial
• What was the bottom line?
• LAMA (tiotropium) is more effective than LABA (salmeterol) in
preventing exacerbations
• LAMA (tiotropium) was comparable to LABA (idacaterol); however,
was slightly more effective at preventing exacerbations
• What were some of the other important details?

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 Patient Case #2: COPD
A primary care physician has been prescribing Advair for patients with
COPD stage B or E and the clinical pharmacist is questioning these
decisions. They would like to make sure patients get the best therapy to
produce positive outcomes.

Is an ICS/LABA combination the most effective agent for stage B or E?

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 FLAME Trial
• What was the bottom line?
• LABA/LAMA is more effective than ICS/LABA for preventing
COPD exacerbations in patients with history in previous year
• What were some of the other important details?

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Bronchodilator Therapy Summary

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 Patient Case #3: COPD
Sampson ‘Smokey’ Chimney is a 57-year-old male with grade 4
(FEV1 25%) and stage E COPD. He is a former smoker and has had a
few (3) COPD exacerbations just in the past year. His current treatment
is Symbicort (HFA) BID plus Spiriva Respimat daily. He recently had
labs, and everything came back normal with an eosinophil count of
55 counts/mL.

What is the most appropriate breathing treatment

recommendation for Smokey?

Are there any other alternative options he could

consider to help reduce his exacerbations?

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 IMPACT Trial
• What was the bottom line?
• Triple therapy with Trelegy once daily resulted in lower
exacerbation and hospitalization rates than dual therapies
• What were some of the other important details?

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 WISDOM Trial
• What was the bottom line?
• Severe COPD patients receiving triple therapy (not combined) who
discontinued ICS resulted in no more adverse outcomes
• What were some of the other important details?

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 Follow-up

Follow-up every 3-6 months

Review
• Symptoms (CAT)
• Exacerbation Hx
Adjust
• Escalate, de-escalate
• Switch inhaler device
Assess
• Inhaler technique
• Non-pharm
• Spirometry (Annually)

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 Alternative Agents
• Macrolide (1 year trial) – MOA? • Other agents:
• Azithromycin - 250 mg daily OR • Theophylline
500 mg three times a week • Oral Prednisone
• Erythromycin – 250 mg BID • Mucolytic agents
• What patients benefit the most • erdosteine, carbocysteine,
from this intervention? n-acetylcysteine
• ? • Statins
• Leukotriene modifiers
• Roflumilast (Daliresp) - MOA?
• Moxifloxacin
• Once daily 500 mcg
• What patients benefit the most
from this intervention?
• ?

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 Vaccinations - RSV
• What was the bottom line?
• Safe and effective in adults ≥ 60 years old
• What were some of the other important details?

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 Ambulatory Care Elective
Asthma & COPD
Dr. Jason Isch – jisch@manchester.edu
Dr. Mallory Carter – mallory.carter@sjrmc.com

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