Disclosure Statement Disclosure statement: these individuals have the following to disclose concerning possible financial or personal relationships with.

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

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

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 was $ billion Smoking-Attributable Morbidity, Mortality, and Economic Costs. Accessed May 15, 2015. Brown, DW. J Gen Intern Med 25(2):

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 Annual average number of deaths from Among Veterans, COPD is about four times more prevalent than in the general population, largely because of tobacco exposure and the high rate of current and past tobacco use. CDC. Annual Deaths Attributable to Cigarette Smoking—United States. Accessed May 2015. 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 $20 billion indirect costs $30 billion direct costs Public Health Strategic Framework for COPD Prevention. Clinicoecon Outcomes Res. 2013; 5: 235–245.

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 Agency for Healthcare Research and Quality, Rockville, MD.

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 Counseling: learn strategies for coping with stress, managing symptoms of nicotine withdrawal, and once they quit, preventing relapse, such as anticipating tempting situations and rehearing coping strategies Treating Tobacco Use and Dependence. April Agency for Healthcare Research and Quality, Rockville, MD. N Engl J Med 2002; 346:

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:

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:

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 Rigotti, NA. N Engl J Med 2002; 346:

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:

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.: CD

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 Agency for Healthcare Research and Quality, Rockville, MD. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD

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, then Nicoderm CQ [package insert]. GlaxoSmithKline. Moon Township, PA Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD

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 weeks Max: 24 pieces/day < 25 cigarettes/day 2 mg every 1-2 hours for 6 weeks, then gradually reduce over an additional 6 weeks Sunmark Nicotine [package insert]. GlaxoSmithKline. Moon Township, PA Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD

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 Dose First cigarette < 30 minutes after awakening 4 mg every 1-2 hours for 6 weeks, then gradually reduced over an additional 6 weeks Max: 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 weeks Nicorette – nicotine lozenge. [package insert]. GlaxoSmithKline. Moon Township, PA Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD

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.: CD

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.: CD

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

Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015
COPD Guidelines Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015

Diagnosing COPD Indicators of COPD Clinical diagnosis
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) COPD, INC.

Assessment of COPD Symptoms Exacerbation 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

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%

Combined Assessment When assessing risk, choose the highest risk according to GOLD grade or exacerbation history

Pharmacologic Treatments
Broadwith, P. New respiratory drugs neck and neck. Royal Chemistry Society. 2015

Beta 2-Agonists Short acting
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 acting albuterol Proventil HFA Inhaler, Neb, tablet 4-6 levalbuterol (NF) Xopenex Inhaler, Neb 6-8 Long acting formoterol (R) Preforomist 12 salmeterol (NF) Serevent Inhaler arformoterol (NF) Brovana Neb Global initiative for chronic obstructive lung disease (GOLD) COPD, INC.

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 acting tiotropium (R) Spiriva Inhaler 24 aclidinium (NF) Tudorza 12

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 fluticasone (NF) Flovent Inhaler

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

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

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 formoterol + mometasone (NF) Dulera salmeterol + fluticasone (NF) Advair

COPD Management

SA anticholinergic PRN SA Beta 2-agonist + SA anticholinergic
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

LA anticholinergic + LA beta 2-agonist
Management- Group B Low risk, more symptoms 1st line Alternative Other LA anticholinergic LA anticholinergic + LA beta 2-agonist SA anticholinergic And/OR SA beta 2-agonist LA beta 2-agonist Theophylline SA: Short acting LA: long acting

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

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 agonist Theophylline LA anticholinergic + PDE-4 inhibitor SA: Short acting LA: Long acting ICS: Inhaled corticosteroid PDE-4 : Phosphodiesterase-4

Administration Technique and Counseling Pearls for COPD Inhalers
Available at the Fayetteville VA Medical Center

Suboptimal control of COPD
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 &/or Both of which bullets may lead to suboptimal control of COPD. = Pharmacist’s Letter 2014; 30(2):300206

Metered-dose inhalers (MDI)
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 For inhaled administration of drugs, there are effectively three single-breath inhaler platforms, each with a unique technical approach. The different types of inhaler devices are likely to be equally effective in delivering medication when used correctly. When choosing a device for a patient you may have to consider the patient’s ability to use the device properly such as their cognition, dexterity or even strength. Metered-dose inhalers typically require priming and shaking prior to use and require good hand-breath coordination. This can be compensated with the use of a spacer. Dry-powder inhalers do not require the same hand-breath coordination as MDI’s as it is breath activated. Soft-mist inhalers – do not require a propellant, therefore are environmentally friendly Pharmacist’s Letter 2014; 30(2):300206

Metered-Dose Inhalers (MDIs)
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) Short acting anticholinergic ipratropium 21 mcg Long-acting beta 2 agonist/corticosteroid budesonide/formoterol 160/4.5 mcg (R) Dosing: 2 inhalations BID Bold agents = formulary Pharmacist’s Letter 2014; 30(2):300206 Pharmacist’s Letter 2014; 30(10):301011 2014 VA/DoD COPD Clinical Practice Guidelines QID = Four times daily; PRN = as needed; BID = twice daily

MDI Agents: Short Acting Bronchodilators
Generic Brand Shake before use Priming Dose Counter albuterol ProAir HFA Yes Before 1st use Not used >14 days 3 sprays Proventil HFA 4 sprays No Ventolin HFA (NF) Not used for >14 days Inhaler dropped levalbuterol (NF) Xopenex HFA Not used for >3 days ipratropium Atrovent HFA Not used >3 days 2 sprays Side note, all of this list of inhalers their beyond use date is the manufacturer’s expiration date on the packaging. BOLD = formulary Clinical pearls: -Beyond Use Date (BUD) = manufacturer’s expiration date on the packaging -Require at least weekly cleaning of device Formulary NF = Non-formulary Pharmacist’s Letter 2014; 30(2):300206 Pharmacist’s Letter 2014; 30(10):301011

MDI Agents: Long Acting Bronchodilators
Generic Brand Shake before use Priming Dose Counter budesonide/ formoterol (R) Symbicort Yes Before 1st use Not used for >3 days Inhaler dropped 2 sprays 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 Please note both of these agents have corticosteroids, so it would be vital that you counsel your pts to rinse their mouth after each use Side note, Symbicort’s beyond use date is 3 months after removal from the foil pouch 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 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 seconds before repeating Spacer/no spacer Whether the pt is using a spacer or not, or using open or closed mouth technique varies the steps for use. This slide walks you through the general steps for MDI use. Open/closed mouth 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 seconds before repeating Pharmacist’s Letter 2014; 30(2):300206 Image: Google search “meter dose inhaler”

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 seconds before repeating Pharmacist’s Letter 2014; 30(2):300206 Image: Google search “meter dose inhalers”

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 seconds before repeating Pharmacist’s Letter 2014; 30(2):300206 Image: Google search “meter dose inhalers”

Dry-Powder Inhalers (DPIs)
Diskus Ellipta Aerolizer Flexhaler Diskhaler HandiHaler Neohaler Podhaler Pressair Twisthaler Pharmacist’s Letter 2014; 30(2):300206 Images: Google search “dry powder inhalers”

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) Pharmacist’s Letter 2014; 30(2):300206

DPIs: Diskus Agents Generic Brand Shake before use Priming
Dose Counter fluticasone/ salmeterol (NF) Advair Diskus 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 Serevent Diskus Clinical pearl: -BUD = 6 weeks after removal from foil pouch or when dose counter reads “0” Do not require cleaning 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 Pharmacist’s Letter 2014; 30(2):300206

DPIs: Aerolizer Agent Long-acting beta-2 agonist (LABA)
formoterol 12mcg (R) 1 inhalation twice daily

DPIs: Aerolizer Agent Generic Brand Shake before use Priming
Dose Counter formoterol (R) Foradil Aerolizer No Yes Clinical pearls: -Do not swallow capsules -BUD = 4 months from date of dispensing -No cleaning required of device

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

DPIs: HandiHaler Agents
Long acting Anticholinergic (LAAC) tiotropium 18 mcg (R) 1 capsule daily 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 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 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 Close the mouthpiece and cap Pharmacist’s Letter 2014; 30(2):300206

Soft-Mist Inhalers 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* Formulary agent Pharmacist’s Letter 2014; 30(2):300206 Package Insert: Combivent Respimat Inhaler.

Soft-Mist Inhaler Agents
Generic Brand Shake before use Priming Dose Counter albuterol/ ipratropium Combivent Respimat No Before 1st 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 tiotropium (R) Spiriva Respimat *Currently not available at the VA* Side note: Spiriva will soon be converting to the Respimat delivery device Tiotropium is restricted, and currently our facility is using the handihaler. Once out of stock, we will transition to the respimat device. Clinical pearls: -Clean weekly (wipe mouthpiece inside/out with damp tissue) -BUD = 3 months after assembly of device Pharmacist’s Letter 2014; 30(2):300206 Package Insert: Combivent Respimat Inhaler

Soft-Mist Inhaler: Assembly
Before inital use Package Insert: Combivent Respimat

Soft-Mist Inhaler: Assembly
Discard the inhaler 3 months after inserting a cartridge or after it locks, whichever comes first 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) Pharmacist’s Letter 2014; 30(2):300206 Package Insert: Combivent

Quick Reference: Available COPD Inhalers
Drug Delivery Strength Dosing Formulary SABAs albuterol levalbuterol MDI 90 mcg 45 mcg 1-2 inh Q4-6h PRN Non-formulary SAMAs ipratropium 21 mcg 1-2 inh Q6h SAMA/SABA ipratropium/ SMI 20/100 mcg 1 inh QID LABAs formoterol salmeterol DPI (capsule) DPI 12 mcg 50 mcg 1 inh BID Restricted LAMAs tiotropium 18 mcg 2.5 mcg 1 inh (DPI) daily 2 inh (SMI) daily Coming soon ICS/LABAs budesonide/ fluticasone/ 160/4.5 mcg 250/50 mcg 2 inh BID 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.

Smoking Cessation and Chronic Obstructive Pulmonary Disease (COPD) Management
Stephanie Cox, PharmD – Rachel Lee, PharmD – Shelby Williams, PharmD – May 29, 2015

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