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Changing the Paradigm: Focus on Preventing Exacerbations in COPD

EDUCATIONAL OBJECTIVES

After completing this activity, participants will be better able to:

1. Provide education to patients regarding chronic obstructive pulmonary disease (COPD) and its

treatments

2. Individualize medications for COPD on the basis of patient needs, interests, and characteristics

3. Provide care consistent with the chronic care model to focus on prevention of exacerbations

4. Recommend pharmacologic therapies consistent with current evidence-based treatment guidelines

5. Describe key aspects of medications used for the treatment of COPD such as clinical efficacy and

administration technique

Post-test/Rationale:

1. All of the following statements about chronic obstructive pulmonary disease (COPD) are TRUE,

except:

A. In COPD, the airways become narrow and damaged, making it difficult to breathe

B. Only cigarette smokers develop COPD***

C. People with COPD are at increased risk for infections

D. People with COPD should stop smoking to slow disease progression

Correct answer: B.

Rationale: Although cigarette smoking is a leading factor for COPD development, other factors may be

involved, including genetics, age, gender, affected lung growth during development and childhood,

occupational and environmental exposures, low socioeconomic status, asthma, bronchitis, and

respiratory infections.

2. According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 Report,

pharmacotherapy for the management of stable chronic obstructive pulmonary disease should be

individualized on the basis of which of the following factors?

A. Symptoms only
B. Risk for future exacerbations only

C. Symptoms and risk for future exacerbations***

D. Symptoms, risk for future exacerbations, and forced expiratory volume in 1 second

Correct answer: C.

Rationale: The 2017 GOLD ABCD tool classifies patients according to their symptoms and risk for

exacerbations, which should guide pharmacotherapy. Previous versions of the GOLD ABCD tool

incorporated symptoms and risk for future exacerbations, as well as forced expiratory volume in 1 second.

3. Which of the following outcomes has not been associated with the use of inhaled medications

for the management of stable chronic obstructive pulmonary disease?

A. Reduction in symptoms

B. Reduction in risk of exacerbations

C. Reduction in severity of exacerbations

D. Reduction in mortality***

Correct answer: D.

Rationale: To date, pharmacologic therapies for the chronic management of stable chronic obstructive

pulmonary disease have been shown to reduce symptoms, reduce the risk and severity of exacerbations,

improve health status, and improve exercise tolerance. A reduction in mortality has not been observed.

4. Which of the following statements regarding the comparative efficacy of medications used in

the management of chronic obstructive pulmonary disease (COPD) is TRUE?

A. Long-acting muscarinic antagonists (LAMAs) are associated with a reduced risk for COPD

exacerbations compared to long-acting beta2-agonists (LABAs)***

B. LABAs are associated with a reduced risk for COPD exacerbations compared to LAMAs

C. Combination therapy with inhaled corticosteroids (ICS) and a LABA is as effective as combination

therapy with a LABA and a LAMA in reducing COPD exacerbations

D. Combination therapy with ICS and a LABA is more effective than combination therapy with a LABA

and a LAMA in reducing COPD exacerbations


Correct answer: A.

Rationale: The Prevention of Exacerbations with Tiotropium in COPD (POET-COPD) study showed that

once-daily tiotropium (a LAMA) was more effective than twice-daily salmeterol (a LABA) at reducing the

risk of exacerbations in patients with moderate to very severe COPD and a history of exacerbations in the

previous year. The Effect of Indacaterol-Glycopyrronium Versus Fluticasone-Salmeterol on COPD

Exacerbations (FLAME) trial showed that a LABA plus a LAMA was noninferior and superior to a LABA

plus an ICS in reducing the annual rate of all COPD exacerbations.

Please refer to following case scenario for questions 5 through 9:

The patient is a 60-year-old female with a past medical history of hypertension, type II diabetes mellitus,

and chronic obstructive pulmonary disease (COPD). She is classified as Group B, according to the

criteria in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 Report. Her current

medications include hydrochlorothiazide 25 mg by mouth daily, lisinopril 5 mg by mouth daily, metformin

1000 mg by mouth twice daily, insulin detemir 20 units at bedtime, and a daily multivitamin. She received

her annual influenza vaccine but has never received any pneumococcal vaccines. She denies alcohol use

and quit smoking cigarettes 3 years ago.

5. According to the GOLD 2017 Report, which of the following medication classes is initially

recommended for the management of this patients stable COPD?

A. Short-acting beta2-agonist

B. Short-acting muscarinic antagonist

C. Long-acting beta2-agonist (LABA) or long-acting muscarinic antagonist (LAMA)***

D. LABA plus inhaled corticosteroids (ICS)

Correct answer: C.

Rationale: According to the GOLD 2017 Report, initial therapy for GOLD Group B is a long-acting

bronchodilator. Either a LABA or a LAMA is recommended. Evidence does not support the use of one

bronchodilator class over another.


6. At her follow-up visit, the patient reports persistent symptoms. She is compliant with her

current COPD regimen and an assessment of inhaler technique indicates appropriate skill.

According to the GOLD 2017 Report, how should pharmacotherapy be escalated?

A. Add a phosphodiesterase-4 inhibitor

B. Switch to a LABA or a LAMA

C. Switch to a LABA plus ICS

D. Switch to a LABA plus a LAMA***

Correct answer: D.

Rationale: According to the GOLD 2017 Report, patients with GOLD Group B disease who experience

persistent symptoms on single long-acting bronchodilator therapy should be escalated to combination

bronchodilation with a LABA plus a LAMA.

7. The patients pharmacotherapy is escalated accordingly. She states that she prefers a once-

daily inhaler dosing regimen. Which of the following inhaled delivery devices accommodates her

preference?

A. Formoterol

B. Aclidinium bromide

C. Olodaterol/tiotropium***

D. Salmeterol/fluticasone

Correct answer: C.

Rationale: Formoterol is a LABA that is dosed twice daily. Aclidinium bromide is a LAMA that is dosed

twice daily. Olodaterol/tiotropium is a combination LABA plus LAMA that is dosed once daily.

Salmeterol/fluticasone is a combination LABA plus ICS that is dosed twice daily.

8. Which of the following counseling points should be provided for the appropriately selected

inhaled delivery device from question #7?

A. Always shake inhaler before use

B. Load powder-containing capsule into device before use


C. Take a slow, deep breath through mouth while pressing dose-release button***

D. To inhale the medicine take a quick, forceful, and deep breath in through your mouth

Correct answer: C.

Rationale: Olodaterol/tiotropipum is classified as a soft-mist inhaler (SMI). SMIs should not be shaken

prior to use (unlike pressurized metered-dose inhalers) and require the patient to take a slow, deep

breath through mouth while pressing dose-release button.

9. According to the 2017 Immunization Schedule for Adults, which vaccination should be

recommended to the patient at this time?

A. Pneumococcal conjugate vaccine (PCV13)

B. Pneumococcal polysaccharide vaccine (PPSV23)***

C. Both PCV13 and PPSV23

D. None of the above

Correct answer: B.

Rationale: The 2017 Immunization Schedule for Adults recommends that patients aged 19 through 64

years with COPD should receive PPSV23. The patient in this case is 60 years old. At age 65 years or

older, the patient should receive the pneumococcal conjugate vaccine (PCV13) and 1 more dose of

PPSV23 at least 1 year after PCV13 and at least 5 years after the most recent dose of PPSV23.

10. Which of the following patient-specific factors needs to be considered when selecting an

inhaled delivery device for the management of chronic obstructive pulmonary disease?

A. Cognitive function

B. Comorbidities

C. Dexterity and strength

D. All of the above***

Correct answer: D.

Rationale: The 2017 Global Initiative for Chronic Obstructive Lung Disease Report emphasizes tailoring

inhaled therapy to the patients specific needs. For example, the patients cognitive function,
comorbidities, dexterity, and strength must be considered, as each inhaled delivery device has

advantages and disadvantages for use. In addition, the medications availability, cost, and reimbursement

must also be considered.