Strategies to improve anxiety and depression in patients with COPD: a mental health perspective.

Chronic obstructive pulmonary disease (COPD) is a pulmonary disease characterized by progressive and potentially reversible symptoms.  In COPD, anxiety and depression are surprisingly common.  This article aimed to comment on the lack of literature of psychological disorders associated with COPD.  First, this study stressed that patients prefer to be treated by non-pharmacological means instead of drug therapy.  Individual and group therapy are useful in treating patients with COPD.  Most antidepressants work the same on depression but have different side effects based on drug class.  This article also stressed that one-third of patients suffering from anxiety and depression due to COPD are untreated.  It also states that one-third of patients with COPD have related anxiety and depression.  Despite all the research conducted by this article it was not able to provide a concise treatment plan but it did specify that mental illness is widely under-diagnosed and under-treated.

This article was interesting to me becasue it was a review article about a topic that I had heard about but had very little knowledge on the matter beforehand.  I heard of COPD but did not know there was such a high correlation between between depression and anxiety and COPD.  I was also curious to see that drug therapy was not the primary source of treatment for this disease state and it was instead preferred to treat using group and individual therapy.  Considering we rarely discuss that form of treatment it was interesting to see that as the principle treatment and learn more about it.

Tselebis A, Pachi A, Ilias I, et al. Strategies to improve anxiety and depression in patients with COPD: a mental health perspective. Neuropsychiatric Disease and Treatment. 2016;12:297-328 

Relevance of dosage in adherence to treatment with long-acting anticholinergics in patients with COPD

Anticholinergics are administered in two different dosing: one is used for 12 hours and second is used for 24 hours. These dosing where studied by Izquierdo and colleagues to find adherence in a large population of over sixteen thousand people. These people were not given anything different than their regular inhalers and were asked to keep their regimens similar to what they were on previously. This study monitored these people for a year and watched for adherence between people using 12 hours vs. 24 hours. Long-acting cholinergics (LAMA) were the main focus of the study, as the researchers believed that 24 hour dosing, which is one time dosing daily, will increase adherence in patients with COPD. As a result, adherence between both long-acting and regular were similar. LAMA was seen to have a very high adherence compared to twice daily dosing, but there was no evidence that showed that twice daily dose caused lower adherence.

This study was short but it’s an evidence towards something that pharmacists have been looking for in patients. Pharmacists role in the community is to help improve the adherence of patients medications with the right guidance and understand the community. This research studied proved that the difference between LAMA and twice daily dose was very similar, even though there was evidence that LAMA had higher adherence. This does not show particularly that patients should switch to one time dosing. Rather, this shows that the adherence comes from patients understanding as these patients in the research study were well explained about their use of anticholinergic for COPD. Would counseling every patient on how to use the medication and following up on the medication, help improve adherence for both LAMA and twice-daily dosing?

 

Izquierdo, J. L., Paredero, J. M., & Piedra, R. (2016). Relevance of dosage in adherence to treatment with long-acting anticholinergics in patients with COPD. International Journal of Chronic Obstructive Pulmonary Disease, 11, 289–293. http://doi.org.pitt.idm.oclc.org/10.2147/COPD.S96948

Oral and Inhaled Corticosteroid Use and the Risk of Recurrent Pulmonary Embolism

The use of oral and inhaled corticosteroids is associated with a variety of adverse effects.  However, they are an accepted necessity in in the treatment of COPD, and provide necessary expansion of airways to help patients struggling to breath.  Many COPD patients suffer pulmonary embolism, and a significant proportion of these patients experience recurrent pulmonary embolism.  There is serious concern that the use of inhaled or oral corticosteroids may increase the lifetime risk of recurrent pulmonary embolism, and raise treatment related morbidity and mortality.  A recent study published in Thrombosis Research attempted to investigate a potential link between current or past use of corticosteroids and the incidence of recurrent pulmonary embolism among patients.

The researchers conducted a nested case-control study that looked at adult patients with a previous PE treated with Vitamin K antagonists.  The study analyzed 1414 PE patients, of which 384 were also later diagnosed with recurrent PE.  The study found that inhaled corticosteroid use only slightly associated with increased risk of recurrent PE, however oral medications did show increased odds of the disease.  In particular, current users of oral formulations were at increased risk (3.74 O.R., 95% CI 2.04-6.87), while past users were actually at a reduced risk (0.46 95% CI 0.28-0.74) compared to patients who never received corticosteroid therapy.  The researchers did admit the study design did not all them to discern whether the risk could be attributed solely on the medications or the underlying inflammatory disease as well.  However, they site evidence that corticosteroid medications show increased blood coagulation factors in healthy volunteers.

Inhaled and oral corticosteroids continue to be a mainstay of treatment for patients with chronic inflammatory diseases like COPD.  However, these disease states put the patients at increased risk for PE, and it would appear that the medications increase the risk of recurrent PE in the same patients.  Given the substantial risk of PE morbidity and mortality, these findings could have severe clinical impact for medication therapy of COPD and other inflammatory diseases of the pulmonary system.  As pharmacists, this association could have a large impact on the therapy management in future patients.  What steps should be taken to refine counseling points on corticosteroids, particularly in oral formulations?  Should the risk be assessed and accepted or denied on a patient-by-patient basis, or is there a better solution to the issue?

Article Link

Sneeboer, Marlous. Hutten, Barbara. Majoor, Christof. Bel, Elizabeth.  Oral and Inhaled Corticosteroid Use and the Risk of Pulmonary Embolism.  Thromres (2016); 140: 46-50.

Tiotropium/Olodaterol: A Review in COPD

This article reviews the efficacy of a new inhaler for COPD (chronic obstructive pulmonary disease) that was approved by the FDA in May 2015 and has since been out on the market. This new inhaler is named Stiolto Respimat (tiotropium/olodaterol), and it was developed by the company Boehringer Ingelheim.

For a quick review, COPD is an overarching term that describes a group of diseases that affect the lungs. People with COPD have difficulty breathing and receiving necessary airflow through their lungs. Patients who receive treatment for COPD typically use long-acting inhalers that are used to improve their chronic state of limited breathing along with “rescue” inhalers that are used to treat acute asthma attacks as needed. Some examples of common, long-acting inhalers already on the market are Advair and Symbicort, and some examples of commonly used “rescue” inhalers already on the market are albuterol inhalers sold under the brand names of Ventolin, ProAir, and Proventil.

Stiolto Respimat is a long-acting inhaler that is a combination of 2 drugs used to treat respiratory problems, which are tiotropium and olodaterol. Tiotropium (bromide) is a long-acting antimuscarinic agent (LAMA), so it works by blocking muscarinic acetylcholine receptors to dilate the bronchioles. Olodaterol is the new drug in this inhaler that has allowed Boehringer Ingelheim to patent and manufacture Stiolto Respimat. Olodaterol is an ultra long-acting beta 2-adrenoreceptor agonist (LABA) that works on beta 2 receptors in the lungs to dilate the bronchioles.

 

This article reviewed clinical trial data and compared Stiolto Respimat to the commonly used inhaler, Advair (fluticasone/salmeterol), that is also a long-acting inhaler for the treatment of COPD. The article determined that Stiolto Respimat seems to be a relatively safe inhaler that has minimal side effects when used correctly and does not have any adverse cardiovascular side effects. It was found to work more efficiently than Advair over a 24 hour period for bronchodilation and lung functioning. The article determined that the combination of tiotropium and olodaterol was more effective when used in combination compared to using the two drug components monotherapeutically. This inhaler can be used once daily, which is convenient in comparison to other long-acting inhalers that must be administered twice daily. Stiolto Respimat was also found to increase exercise capacity in COPD patients and the amount of gas they can inhale into their lungs.

In conclusion, this article has shed a positive light on Stiolto Respimat as it makes it way into the medical world through the new few years. It seems to be a great addition to current therapies for COPD, and could be a good alternative to COPD patients who are allergic to drugs in some of the other inhalers. I find it interesting how drug developers have combined drugs with different mechanism of actions in inhalers to maximize the efficacy of inhaled therapies. These newer combination therapies have been very popular in the treatment of COPD since they came out a few years ago (I’m thinking of inhalers such as Advair, Symbicort, and Ventolin). I am thinking that I want to become a community pharmacist, so I am interested in learning more about the treatment options for COPD and all of the side effects that come with these treatments.

My question posed to colleagues: How are the mechanism of action between Advair (fluticasone/salmeterol) and Stiolto Respimat (tiotropium/olodaterol) different?

Dhillon, S. Tiotropium/olodaterol: A review in COPD. Drugs. 2016;76:135-146.

 

Effect of Acetazolamide vs Placebo on Duration of Invasive Mechanical Ventilation Among Patients With Chronic Obstructive Pulmonary Disease A Randomized Clinical Trial

Chronic Obstructive Pulmonary disease(COPD) is a series of lung diseases that make it extremely difficult for persons affected with this disease to breath properly. It is a frequent cause of ICU admissions. Treatment requires invasive mechanical ventilation because noninvasive ventilation methods often are not successful at alleviating the effects of this disease.

Acetalzolamide is a medication used as a noninvasive method of relieving COPD symptoms. However this medication does not have the FDA indication to treat COPD and no studies were done to see if this medication was even effective in doing such. This article is a double blind study that had patients taking 500-1ooo mg of Acetazolamide to test its effectiveness as a COPD treating agent.

The results of the study actually found that there was NO difference in symptoms when Acetazolamide was administered. However, it is important to note that the researchers conducting the study, said that certain aspects of the study could have been underpowered to establish statistical significance.

Why was this drug allowed to be used for so long to treat a condition it was not FDA approved to treat without first having thorough research done proving its efficacy? What does this mean or how does this change the ways in which we introduce a new drug therapy?

Citation:

Faisy C, Meziani F, Planquette B, et al. Effect of Acetazolamide vs Placebo on Duration of Invasive Mechanical Ventilation Among Patients With Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial. JAMA. 2016;315(5):480-488. doi:10.1001/jama.2016.0019.

Pharmacists can improve COPD care

Chronic obstructive pulmonary disease is a progressive disease disturbing a patient’s ability to breath and affects 6.3% of adults nationally. It is described by the CDC as a group of diseases causing air flow blockage and can include emphysema, chronic bronchitis, and asthma.

In this article, a pharmacy resident noticed that COPD was a growing issue in the patient population he cared for and began a program to establish a pharmacist managed COPD clinic, much like other programs for anticoagulation therapy or infectious disease. He stabled a program to use his ability and knowledge of pharmacist to optimize COPD therapy and monitor patient inhaler techniques in collaboration with other healthcare providers. This clinic also made it possible for patient’s prescribed an inhaler during their hospital stay to keep the device after discharge. Previously these inhalers were going to waste and being thrown out, while patients were going without their medication. Through discharge counseling and education at the clinic, patient health improved, showing a decrease from 21% to 9% patients readmitted within 30 days after discharge. Even after his residency has ended, patients are still referred to this COPD clinic highlighting its success.

This article represents the benefit that pharmacist intervention and management of patients’ disease states and therapy can have. Furthermore, as future pharmacists we must serve as advocates for our patients and recognize when their needs are not being met. The pharmacist in this article was able to identify a problem and create a solution to provide the best possible care to his patients. As we have learned last semester, it is essential to recognize situations where a pharmacist can optimize patient care in an area that we are passionate about to create our own jobs and learning opportunities, much like this pharmacy resident has done.

Reference:

Am J Health-Syst Pharm. 2015;72:2004-2006.

http://www.ajhp.org/content/72/23/2004.full.pdf+html

Acetazolamide to decrease invasive mechanical ventilation in critically ill patients with Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease (COPD) can lead to intensive care unit (ICU) admission with some patients requiring the need for invasive mechanical ventilation. Acetazolamide has been used as a respiratory stimulant in patients with COPD and metabolic alkalosis. Faisy and colleagues conducted the DIABLO study to determine whether acetazolamide reduces mechanical ventilation duration in critically ill patients with COPD and metabolic alkalosis. The DIABLO study was a randomized, double-blind, multicenter, parallel-group trial conducted from October 2011 to July 2014 in 15 ICU’s in France. Patients were randomized to receive either 500 mg or 1000 mg (if loop diuretics were co-prescribed) of acetazolamide twice daily or placebo (10mL of saline). The primary end point of the study was duration of invasive mechanical ventilation via endotracheal intubation or tracheotomy with secondary end points including alterations in arterial blood gas and respiratory parameters, weaning duration, adverse events, use of noninvasive ventilation after extubation, successful weaning, the duration of ICU stay, and in-ICU mortality. Of the 380 patients that completed the study, 187 were randomzed to the acetazolamide treatment group and 193 to the placebo treatment group. The study resulted in a total duration of invasive ventilation median of 136.5 hours in the acetazolamide group versus 163.0 hours in the placebo group, for a between group difference of -16.0 hours, which did not differ significantly (statistically). Secondary end point analysis between the groups showed no respiratory stimulant effect on respiratory rate, tidal volume, or median minute ventilation change. However, daily changes in serum bicarbonate (between group difference, −0.8 mEq/L; 95% CI, −1.2 to −0.5 mEq/L; P < .001) and number of days with metabolic alkalosis (between-group difference, −1; 95% CI, −2 to −1 days; P < .001) decreased significantly more in the acetazolamide group. The study concluded that patients with COPD receiving invasive mechanical ventilation that were treated with acetazolamide, compared with placebo, showed no statistically significant reduction in duration of invasive mechanical ventilation.

It was noted in the study that although the data suggested that no statistically significant change was observed, there was a reduction in the drug treatment group by 16 hours indicating a clinically significant result. The sooner that critically ill patients can be weaned off artificial respiration, the sooner they are to be discharged.
JAMA. 2016;315(5):480-88.