Pharmacological Treatment Options for ____COPD (Anti-inflammatory Agents)______

Tri Nguyen, PharmD Candidate 2007

Corticosteroids / Inhaled Glucocoticosteroids / Combination LABA and glucocorticosteroid / Long-Term Oxygen Therapy
Product Availability
Generic (Brand) / prednisone (Deltasone)
1mg, 2.5mg, 5mg, 10mg, 20mg, 50mg / budesonide (Pulmicort) 100, 200, 400 mcg
fluticasone (Flovent) 50-500 mcg
triamcinolone( Azmacort) 100 mcg / fluticasfne/salmeterol (Advair) / ** stable outpatients receiving optimal pharmacotherapy should be given oxygen if:
-resting PaO2 of <55mg Hg
-evidence of right heart failure, polycythemia,, or impaired neuropsychiatric fx with PaO2 <60mg Hg **
Mechanism
of Action / -decrease inflammation by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability / -Controls the rate of protein synthesis; depresses the migration of polymorphonuclear leukocytes, fibroblasts; reverses capillary permeability and lysosomal stabilization at the cellular level to prevent or control inflammation / **see MOA of LABA and glucocorticosteroids
EFFICACY
(Indication/Use, Clinical Data Support) / -lack of consensus about efficacy of oral and inhaled glucocorticoids for COPD
-considered 2nd tier therapy after adequate trial of inhaled anticholinergics, sympathomimetics and possibly theophylline (due to SEs)
-should only be used in patients who show objective benefit during steroid trial / -used in stages 3-4 if repeated exacerbations / -can be used in stages 1-4
SAFETY
(Major Drug Interactions,
Pre-cautions, Contra-indications,
Adverse Effects,
Pregnancy Risk Category) / Adverse effects:
-Insomnia, nervousness, indigestion, dizziness, headache, DM, glucose intolerance, arthralgia, Cushing’s syndrome, edema, muscle wasting, osteoporosis, pituitary-adrenal axis suppression
Contraindications:
-hypersensitvity to prednisone, serious infections, systemic fungal infections
Precautions:
-withdraw therapy with gradual tapering, may retard bone growth, caution in patients with hypothyroidism, cirrhosis, CHF, ulcerative colitis, thromboembolic disorders
Drug interactions:
-CYP3A4 substrate and inhibitor cyclosporine, oral contraceptives / Advers effects:
>10%: Central nervous system: Headache (up to 21%)
Gastrointestinal: Nausea (up to 11%) Respiratory: Respiratory infection, rhinitis
Contraindications:
Hypersensitivity to any component of the formulation
Precautions:
May cause hypercorticism and/or suppression of hypothalamic-pituitary-adrenal (HPA) axis, particularly in younger children
-reduction in growth velocity in pediatric patients
-May suppress the immune system
Drug Interactions:
CYP3A4
Cimetidine
Proton pump inhibitors / Adverse effects/contraindications/precautions/
drug interaction
**see information for LABA and glucocorticosteroids
Dosage & Administration
(Include renal and/or hepatic adjustments) / -short to intermediate-acting glucocorticoid at lowest effective dose (prednisone 7.5mg/day) preferred to minimize suppression of Pituitary-adrenal axis
-dose adjustment needed in patients with liver disease/dysfunction and patients with hyperthyroidism / fluticasone: Flovent® HFA: 44 mcg/inhalation (10.6 g) [120 metered doses] Flovent® HFA: 110 mcg/inhalation (12 g) [120 metered doses] Flovent® HFA: 220mcg/inhalation (12 g) [120 metered doses
budesonide: “Low” dose: 200-400 mcg/day (1-2 inhalations/day) “Medium” dose: 400-600 mcg/day (2-3 inhalations/day) “High” dose: >600 mcg/day (>3 inhalation/day)
triamcinolone:Children 6-12 years: 100-200 mcg 3-4 times/day or 200-400 mcg twice daily; maximum dose: 1200 mcg/day Children >12 years and Adults: 200 mcg 3-4 times/day or 400 mcg twice daily; maximum dose: 1600 mcg/day / COPD: Adults: Advair Diskus®: Fluticasone 250 mcg/salmeterol 50 mcg twice daily, 12 hours apart
Monitoring
(Efficacy and Toxicity Parameters) / Efficacy: PFT, coughing, wheezing, dyspnea, beta agonist use
Toxicity: Blood glucose, BP, electrolytes / Efficacy: PFT, coughing, wheezing, dyspnea, beta agonist use
Toxicity: Blood glucose, BP, electrolytes / **See Monitoring for LABA and glucocorticosteroids**
Patient Education / -take as directed
-monitor BP daily
-signs and symptoms of adrenal insufficiency should be monitored in patients with history of use / Monitor growth in children
Proper inhaler use
-proper inhalation use / **see education for LABA and glucocorticosteroids**
Cost
(1-month) / Cost varies with dosing / Triamcinolone: 55 mcg/ACT (16.5): $67.99
Budesonide: 200 mcg/INH (1): $148.12
Fluticasone: not found / 100-50 mcg/dose (60): $113.99
250-50 mcg/dose (60): $147.99
500-50 mcg/dose (60): $200.99
References
(Guidelines, Drug Info Sources) / See below

**Konzem SL, Stratton, MA. COLD. In: Dipiro JT, Talbert, RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy: A Pathophysiologic Approach 6th Edition. New York: Mcgraw-Hill Companies, Inc; Chapt. 27

**Lexi-Comp Online™ (database on the Internet). Hudson(OH): Lexi-Comp.c1978-2006 (cited: 2006 September). Lexi-Drugs. Available from:

Tri Nguyen, PharmD Candidate 2007Pharmacotherapy Presentation – Pharmaceutical Care Rotation

University of MarylandSchool of PharmacyHappy Harry’s PharmacyPatientCareCenter, Perryville, MD