Smoking Cessation and Chronic Obstructive
Pulmonary Disease (COPD) Management
Stephanie Cox, PharmD, PGY2 Ambulatory Care Resident
Rachel Lee, PharmD, PGY1 Pharmacy Resident
Shelby Williams, PharmD, PGY1 Pharmacy Resident
May 29, 2015
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
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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
VETERANS HEALTH ADMINISTRATION
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Smoking Cessation
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
VETERANS HEALTH ADMINISTRATION
Smoking-Attributable Morbidity, Mortality, and Economic Costs.
http://www.surgeongeneral.gov/library/reports/50-years-ofprogress/sgr50-chap-12.pdf. Accessed May 15, 2015.
Brown, DW. J Gen Intern Med 25(2): 147-9.
4
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
VETERANS HEALTH ADMINISTRATION
CDC. Annual Deaths Attributable to Cigarette Smoking—United States.
http://www.cdc.gov/tobacco/data_statistics/tables/health/attrdeaths/index.htm. Accessed May 2015. 5
COPD: Challenges and Opportunities for Federal Medicine. COPD Prevalence among Veterans Related to
High Smoking Rates. U.S. Medicine.
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
VETERANS HEALTH ADMINISTRATION
Public Health Strategic Framework for COPD Prevention.
www.cdc.gov/copd/pdfs/Framework_for_COPD_Prevention.pdf
Clinicoecon Outcomes Res. 2013; 5: 235–245.
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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
VETERANS HEALTH ADMINISTRATION
Treating Tobacco Use and Dependence. April 2013. Agency for Healthcare Research
7
and Quality, Rockville, MD. http://www.ahrq.gov/professionals/cliniciansproviders/guidelines-recommendations/tobacco/clinicians/update/index.html.
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
VETERANS HEALTH ADMINISTRATION
Treating Tobacco Use and Dependence. April 2013. Agency for Healthcare Research
and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians8
providers/guidelines-recommendations/tobacco/clinicians/update/index.html.
N Engl J Med 2002; 346:506-512.
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
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Rigotti, NA. N Engl J Med 2002; 346:506-512.
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
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Rigotti, NA. N Engl J Med 2002; 346:506-512.
Assessment during Patient Visits - NEJM
If 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
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Rigotti, NA. N Engl J Med 2002; 346:506-512.
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
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Rigotti, NA. N Engl J Med 2002; 346:506-512.
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
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Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
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
VETERANS HEALTH ADMINISTRATION
Treating Tobacco Use and Dependence. April 2013. Agency for Healthcare Research
and Quality, Rockville, MD. http://www.ahrq.gov/professionals/clinicians14
providers/guidelines-recommendations/tobacco/clinicians/update/index.html.
Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
Nicotine Patch
• Dosing: number of cigarettes smoked per day
# of Cigarettes/day
> 10 cigarettes/day
Patch Dosing
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, then
7 mg/day x 2 weeks
• 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)
VETERANS HEALTH ADMINISTRATION
Nicoderm CQ [package insert]. GlaxoSmithKline. Moon Township, PA. 2014.
Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
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Nicotine Gum
• Dosing: number of cigarettes smoked each day
# of Cigarettes/day
≥ 25 cigarettes/day
< 25 cigarettes/day
Dose
4 mg every 1-2 hours for 6 weeks, then
gradually reduce over an additional 6 weeks
Max: 24 pieces/day
2 mg every 1-2 hours for 6 weeks, then
gradually reduce over an additional 6 weeks
Max: 24 pieces/day
• Pharmacotherapy pearl: “chew and park” for 30 minutes
• Side effects: hiccoughs, GI disturbances, jaw pain, and orodental problems
VETERANS HEALTH ADMINISTRATION
Sunmark Nicotine [package insert]. GlaxoSmithKline. Moon Township, PA. 2014.
Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
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Nicotine Lozenge
• Dosing: timing of first cigarette of day
Timing
Dose
First cigarette < 30
4 mg every 1-2 hours for 6 weeks, then gradually
minutes after awakening reduced over an additional 6 weeks
Max: 5 lozenges every 6 hours or 20 per day
First cigarette ≥ 30
2 mg every 1-2 hours for 6 weeks, then gradually
minutes after awakening reduced over an additional 6 weeks
Max: 5 lozenges every 6 hours or 20 per 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
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Nicorette – nicotine lozenge. [package insert]. GlaxoSmithKline. Moon Township, PA. 2014.
Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
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
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Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
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)
VETERANS HEALTH ADMINISTRATION
Chantix [package insert]. Pfizer Labs. New York, NY. Feb 2015.
Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD009329.
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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
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COPD Guidelines
Global Initiative for Chronic Obstructive Lung Disease (GOLD)
2015
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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
VETERANS HEALTH ADMINISTRATION
Global initiative for chronic obstructive lung disease (GOLD). 2015. COPD,
INC.
22
Assessment of COPD
• Symptoms
– COPD Assessment Test (CAT)
– Modified British Medical Research Council (mMRC) scale
Symptoms
Score
Less symptoms
mMRC 0-1 or CAT <10
More symptoms
mMRC ≥ 2 or CAT ≥10
• Exacerbation
risk
# exacerbation/ year or hospitalization
Low
≤ 1 or no hospitalization for exacerbation
High
≥ 2 and ≥ 1 hospitalization for exacerbation
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Assessment of COPD
• Severity level
Gold level
Severity
FEV1 Predicted
1
Mild
≥ 80%
2
Moderate
50-79%
3
Severe
30-49%
4
Very severe
<30%
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Combined Assessment
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Pharmacologic Treatments
VETERANS HEALTH ADMINISTRATION
Broadwith, P. New respiratory drugs neck and neck. Royal
Chemistry Society. 2015
26
Beta 2-Agonists
• Mechanism of Action (MOA): Binds to beta-2 receptors on the
bronchial smooth muscle to induce bronchodilation
Generic
Brand
Formulations
DOA (hours)
albuterol
Proventil HFA
Inhaler, Neb, tablet
4-6
levalbuterol (NF)
Xopenex
Inhaler, Neb
6-8
formoterol (R)
Preforomist
Inhaler, Neb
12
salmeterol (NF)
Serevent
Inhaler
12
arformoterol (NF)
Brovana
Neb
12
Short acting
Long acting
• Adverse effects: cardiac rhythm disturbance and tremor
VETERANS HEALTH ADMINISTRATION
Global initiative for chronic obstructive lung disease (GOLD). 2015. COPD, INC.
Anticholinergics
• MOA: Blocks acetylcholine from binding muscarinic receptors
to promote bronchodilation
Generic
Brand
Formulations
DOA (hours)
Atrovent HFA
Inhaler, Neb
6-8
tiotropium (R)
Spiriva
Inhaler
24
aclidinium (NF)
Tudorza
Inhaler
12
Short acting
ipratropium
Long acting
• Adverse effects: dry mouth and bitter metallic taste
• Avoid combination of short and long-acting anticholinergics
therapy
VETERANS HEALTH ADMINISTRATION
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Inhaled Corticosteroid
• MOA: anti-inflammatory and relieves muscle spasm
Generic
Brand
Formulations
beclomethasone (NF)
QVAR
Inhaler, Neb
budesonide (NF)
Pulmicort
Inhaler, Neb
fluticasone (NF)
Flovent
Inhaler
• Adverse effects: oral candidiasis and hoarse voice
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Phosphodiesterase-4 Inhibitors
• MOA: Anti-inflammatory
Generic
Brand
Formulation
DOA (hours)
roflumilast (NF)
Daliresp
Oral pill
24
• Adverse effects: nausea, reduce appetite, headache,
sleep disturbance and abdominal pain
• Criteria for Use
– Requires a Non-Formulary consult
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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
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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
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COPD Management
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Management- Group A
• Low risk, less symptoms
1st line
Alternative
Other
SA anticholinergic PRN
SA Beta 2-agonist + SA
anticholinergic
Theophylline
SA beta 2-agonist PRN
LA anticholinergic
LA beta 2-agonist
SA: Short acting
LA: long acting
VETERANS HEALTH ADMINISTRATION
Management- Group B
• Low risk, more symptoms
1st line
Alternative
LA anticholinergic
LA anticholinergic + LA beta 2-agonist
LA beta 2-agonist
Other
SA anticholinergic
And/OR
SA beta 2-agonist
Theophylline
SA: Short acting
LA: long acting
VETERANS HEALTH ADMINISTRATION
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Management- Group C
• High risk, less symptoms
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
SA: Short acting LA: Long acting
ICS: Inhaled corticosteroid PDE-4 : Phosphodiesterase-4
VETERANS HEALTH ADMINISTRATION
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Management- Group D
• High risk, more symptoms
1st 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 acting
ICS: Inhaled corticosteroid PDE-4 : Phosphodiesterase-4
VETERANS HEALTH ADMINISTRATION
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Administration Technique and
Counseling Pearls for COPD Inhalers
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Background
At least 50% of patients who are prescribed
inhalers may be using them incorrectly
&/or
Health care providers may have a knowledge
gap when it comes to the correct use of
different inhaler devices
=
Suboptimal control of COPD
VETERANS HEALTH ADMINISTRATION
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Pharmacist’s Letter 2014; 30(2):300206
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
VETERANS HEALTH ADMINISTRATION
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Pharmacist’s Letter 2014; 30(2):300206
Metered-Dose Inhalers (MDIs)
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Images: Google Search “metered-dose inhalers”
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
VETERANS HEALTH ADMINISTRATION
QID = Four times daily; PRN = as needed; BID = twice daily
Pharmacist’s Letter 2014; 30(2):300206
Pharmacist’s Letter 2014; 30(10):301011
2014 VA/DoD COPD Clinical Practice Guidelines
42
MDI Agents: Short Acting Bronchodilators
Generic
albuterol
Brand
Shake
before use
ProAir HFA
Yes
Before 1st use
Not used >14 days
3 sprays
Yes
Yes
Before 1st use
Not used >14 days
4 sprays
No
Yes
Before 1st use
Not used for >14 days
Inhaler dropped
4 sprays
Yes
4 sprays
Yes
2 sprays
Yes
Proventil HFA
Ventolin HFA
(NF)
Priming
levalbuterol
(NF)
Xopenex HFA
Yes
Before 1st use
Not used for >3 days
ipratropium
Atrovent HFA
No
Before 1st use
Not used >3 days
Dose Counter
Clinical pearls:
-Beyond Use Date (BUD) = manufacturer’s expiration date on the packaging
-Require at least weekly cleaning of device
VETERANS HEALTH ADMINISTRATION
Formulary
NF = Non-formulary
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Pharmacist’s Letter 2014; 30(2):300206
Pharmacist’s Letter 2014; 30(10):301011
MDI Agents: Long Acting Bronchodilators
Generic
budesonide/
formoterol
(R)
Brand
Symbicort
Shake
before use
Yes
Priming
Before 1st use
Not used for >3 days
Inhaler dropped
Dose Counter
2 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
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Pharmacist’s Letter 2014; 30(2):300206
Pharmacist’s Letter 2014; 30(10):301011
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
Spacer/no spacer
•
Press the canister down while inhaling deeply and slowly through the mouth
Open/closed mouth
•
•
•
Hold breath for as long as comfortably possible (~10 seconds)
Breathe out slowly
Wait 30-60 seconds before repeating
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Pharmacist’s Letter 2014; 30(2):300206
Pharmacist’s Letter 2014; 30(10):301011
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
VETERANS HEALTH ADMINISTRATION
Pharmacist’s Letter 2014; 30(2):300206
Image: Google search “meter dose inhaler”
46
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
VETERANS HEALTH ADMINISTRATION
Pharmacist’s Letter 2014; 30(2):300206
Image: Google search “meter dose inhalers”
47
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
VETERANS HEALTH ADMINISTRATION
Pharmacist’s Letter 2014; 30(2):300206
Image: Google search “meter dose inhalers”
48
Dry-Powder Inhalers (DPIs)
•
•
•
•
•
Diskus
Ellipta
Aerolizer
Flexhaler
Diskhaler
VETERANS HEALTH ADMINISTRATION
•
•
•
•
•
HandiHaler
Neohaler
Podhaler
Pressair
Twisthaler
Pharmacist’s Letter 2014; 30(2):300206
Images: Google search “dry powder inhalers”
49
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
VETERANS HEALTH ADMINISTRATION
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Pharmacist’s Letter 2014; 30(2):300206
DPIs: Diskus Agents
Generic
Brand
Shake before use
Priming
Dose Counter
fluticasone/
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
VETERANS HEALTH ADMINISTRATION
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Pharmacist’s Letter 2014; 30(2):300206
DPIs: Diskus
General 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
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Pharmacist’s Letter 2014; 30(2):300206
DPIs: Aerolizer Agent
• Long-acting beta-2 agonist (LABA)
– formoterol 12mcg (R)
• 1 inhalation twice daily
VETERANS HEALTH ADMINISTRATION
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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
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DPIs: Aerolizer Agent
General 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
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56
DPIs:
HandiHaler Agents
• Long acting Anticholinergic (LAAC)
– tiotropium 18 mcg (R)
• 1 capsule daily
VETERANS HEALTH ADMINISTRATION
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Pharmacist’s Letter 2014; 30(2):300206
Dry-Powder Inhaler (DPI):
HandiHaler Agent
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 needed
Open 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
58
Pharmacist’s Letter 2014; 30(2):300206
Dry-Powder Inhaler (DPI): HandiHaler
General 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
•VETERANS
CloseHEALTH
the mouthpiece
and cap
ADMINISTRATION
Pharmacist’s Letter 2014; 30(2):300206
59
Soft-Mist Inhalers
VETERANS HEALTH ADMINISTRATION
60
Image: Google search “soft-mist inhalers”
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*
VETERANS HEALTH ADMINISTRATION
Pharmacist’s Letter 2014; 30(2):300206
Package Insert: Combivent Respimat Inhaler.
61
Soft-Mist Inhaler Agents
Generic
albuterol/
ipratropium
tiotropium
(R)
Brand
Combivent
Respimat
Spiriva
Respimat
*Currently not
available at the VA*
Shake before
use
Before use
Not used for >21 days
Spray inhaler into the
air until a visible spray
is seen, then spray 3
more times
Not used for >3 days
1 spray
1st
No
Dose
Counter
Priming
1st
Before use
Not used for >21 days
No
Not used for >3 days
Spray inhaler into the
air until a visible spray
is seen, then spray 3
more times
No
No
1 spray
Clinical pearls:
-Clean weekly (wipe mouthpiece inside/out with damp tissue)
-BUD = 3 months after assembly of device
VETERANS HEALTH ADMINISTRATION
Pharmacist’s Letter 2014; 30(2):300206
Package Insert: Combivent Respimat Inhaler
62
Soft-Mist Inhaler: Assembly
• Before inital use
VETERANS HEALTH ADMINISTRATION
63
Package Insert: Combivent Respimat
Soft-Mist Inhaler: Assembly
VETERANS HEALTH ADMINISTRATION
64
Package Insert: Combivent Respimat
Soft-Mist Inhaler: Respimat
General Steps for Use “TOP”
Hold inhaler upright
Turn the base in the direction of the arrows until it clicks
Flip the cap until it snaps open
Breathe 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)
VETERANS HEALTH ADMINISTRATION
Pharmacist’s Letter 2014; 30(2):300206
Package Insert: Combivent
65
Quick Reference:
Available COPD Inhalers
Drug
Delivery
Strength
Dosing
Formulary
albuterol
levalbuterol
MDI
MDI
90 mcg
45 mcg
1-2 inh Q4-6h PRN
Formulary
Non-formulary
SAMAs
ipratropium
MDI
21 mcg
1-2 inh Q6h
Formulary
SAMA/SABA
ipratropium/
albuterol
SMI
20/100 mcg
1 inh QID
Formulary
formoterol
salmeterol
DPI (capsule)
DPI
12 mcg
50 mcg
1 inh BID
Restricted
Non-formulary
LAMAs
tiotropium
DPI (capsule)
SMI
18 mcg
2.5 mcg
1 inh (DPI) daily
2 inh (SMI) daily
Restricted
Coming soon
MDI
160/4.5 mcg
2 inh BID
Restricted
DPI
250/50 mcg
1 inh BID
Non-formulary
SABAs
LABAs
ICS/LABAs
budesonide/
formoterol
fluticasone/
salmeterol
VETERANS HEALTH ADMINISTRATION
66
2014 VA/DoD COPD Clinical Practice Guidelines.
Self-Assessment
• Break into groups and demonstrate proper
inhaler administration technique with each of
the various delivery devices.
VETERANS HEALTH ADMINISTRATION
67
Smoking Cessation and Chronic Obstructive
Pulmonary Disease (COPD) Management
Stephanie Cox, PharmD – stephanie.cox4@va.gov
Rachel Lee, PharmD – rachel.lee@va.gov
Shelby Williams, PharmD – shelby.williams2@va.gov
May 29, 2015