This document presents a case of a 59-year-old man with COPD and a history of smoking who is experiencing increased shortness of breath. After assessing the patient according to GOLD 2017 guidelines and categorizing him as GOLD stage 2B, a pharmaceutical care plan is developed that includes stopping his current COPD medications, starting new medications, smoking cessation counseling, and patient education. Newly approved COPD medications including Bevespi Aerosphere, Stiolto Respimat, and Utibron Neohaler are also briefly summarized.

1. COPD
case presentation
Prepared by: Sara Abudahab, Ala’a Alhayek and Amani Almani
Supervised by: Dr. Abla Albsoul
Jordan UniversityFaculty of pharmacy

2. Outline
 Patient presentation
 COPD assessment according to GOLD 2017
 Pharmaceutical care plan
 Smoking cessation
 Newly approved drugs for COPD
 References

3. Treading on Thin Air
Patient Presentation
Chief Complaint
“My wife says I need to get my lungs checked. Ever since we moved, I’m
having a hard time breathing.”
HPI
D.M is a 59-year-old man who is presenting to a new provider at the
family medicine clinic today with complaints of increasing shortness of
breath. He points out that he first noticed some difficulty catching his
breath at his job 3 years ago. He had been able to carry heavy loads up
and down a flight of stairs daily for the last 35 years without any
problem. However, his shortness of breath began to make this very
difficult. Coincidently at that time, he accepted a managerial position at
his company that significantly reduced his activity level.

4. Patient Presentation cont.
HPI
After taking this position, he no longer noticed any problems, but
admits that he avoids activities that cause him to physically
exert himself. He noticed significant shortness of breath again
after he moved to Colorado from a lower elevation 2 months ago
to be closer to his grandchildren. His shortness of breath is worst
when he is outside playing with his grandchildren. His previous
physician had placed him on salmeterol/fluticasone (Advair) one
inhalation twice daily 2 years ago. He thinks his physician
initiated the medication for the shortness of breath, but he is
not entirely sure. He is hoping to get a good medication that will
help relieve his shortness of breath because the gardening season
is right around the corner, and he enjoys this hobby.

5. PMH
CAD (MI 7 years ago, resulting in stent
placement at that time; additional stent
placed 2 years ago; normal ECHO and stress
test 3 months ago)
Chronic bronchitis × 8 years (has had one
exacerbation in the last 12 months;
received oral antibiotic treatment but was
not hospitalized)
Cervical radiculopathy
Patient Presentation cont.

6. FH
Father with COPD (smoked a pipe for 40 years). Mother with
coronary artery disease and cerebrovascular disease.
SH
He lives with his wife, who is a nurse. He has a 40 pack-year
history of smoking. When he had an MI at age 52, he quit smoking
temporarily. At present, he continues to smoke five to six
cigarettes per day. He drinks two to three beers most nights of the
workweek.
Patient Presentation cont.

7. Meds
Aspirin 81 mg po once daily
Clopidogrel 75 mg po once daily
Rosuvastatin 20 mg po once daily
Fluticasone/salmeterol 100/50, one
inhalation BID
OTC ibuprofen 200 mg po four to six times
daily PRN neck pain
Bupropion SR 150 mg twice daily
NKDA
Patient Presentation cont.

8. ROS
(+) Chronic cough with sputum production; (+) exercise intolerance
Physical Examination
Gen
WDWN (well-developed well-nourished) man in NAD (no abnormality
detected)
VS
BP 110/68, P 60, RR 16, T 37°C; Wt 82 kg, Ht 5′9″ (BMI=26.7 i.e
overweight);
pulse ox 93% on RA
Patient Presentation cont.

9. Skin
Warm, dry; no rashes
HEENT
Normocephalic; PERRLA, EOMI; normal sclerae; mucous
membranes are moist; TMs intact; oropharynx clear
Neck/Lymph Nodes
Supple without lymphadenopathy
Lungs
Decreased breath sounds; no rales, rhonchi, or crackles
CV
RRR without murmur; normal S1 and S2
Patient Presentation cont.

10. Abd
Soft, NT/ND; (+) bowel sounds; no organomegaly
Genit/Rect
No back or flank tenderness; normal male genitalia
MS/Ext
No clubbing, cyanosis, or edema; pulses 2+ throughout
Neuro
A & O × 3; CN II—XII intact; DTRs 2+; normal mood and affect
Patient Presentation cont.

11. Lab data Normal Range
Na 135 mEq/L 135–145 mEq/L
K 4.2 mEq/L 3.3–4.9 mEq/L
Cl 108 mEq/L 97–110 mEq/L
CO2 26 mEq/L 22–30 mEq/L
BUN 19 mg/dL 8–25 mg/dL
SCr 1.1 mg/dL 0.7–1.3 mg/dL (male)
Glu 89 mg/dL 65–109 mg/dL
Hgb 13.5 g/dL 13.8–17.2 g/dL (male)
Hct 41.2% 40.7–50.3% (male)
Plt 195 × 103/mm3 140–440 × 103/μL
WBC 5.4 × 103/mm3 4–10 × 103/mm3
AST 40 IU/L 11–47 IU/L
ALT 19 IU/L 7–53 IU/L
T. bili 1.1 mg/dL 0.3–1.1 mg/dL
Alb 3.8 g/dL 3.5–5.0 g/dL
Ca 9.6 mg/L 8.6–10.3 mg/dL
Mg 3.6 mg/L (0.36 mg/dL) 1.58–2.68 mg/dL
Phos 2.9 mg/dL 2.5–4.5 mg/dL
Patient Presentation cont.

12. Pulmonary Function Tests (During Clinic Visit Today)
Predicted FEV1 is 4.02 L FVC = 4.5 L
Prebronchodilator FEV1 = 2.98 L (2.98/4.02= 0.74)
Postbronchodilator FEV1 = 2.75 L (2.75/4.02= 0.68)
Patient Presentation cont.

14. COPD Assessment Tool (CAT)

15. mMRC

16. COPD Assessment from GOLD 2017

17. Pharmacologic treatment according to
GOLD 2017 for group B :

19. Pharmaceutical Care Plan
Date Medical
condition
TRPs Goal Current Status Interventions Follow-up
5/3/2017 COPD Efficacy
More effective drug is available/
recommended
The patient requires additional
therapy because of actual or
potential therapy failure
(Fluticasone and Salmetrol)
(Bupropion)
 Reduce Symptoms :
Relive symptoms
Improve exercise tolerance
Improve health status
 Reduce Risk :
Prevent disease progression
Prevent and treat exacerbation
Reduce mortality
 Smoking cessation
Uncontrolled
(GOLD 2 B)
(moderate COPD)
FEV2 post-
bronchodilator =
68%
Smoker (5-6
cigarettes day )
Pharmacological
1- D/C Fluticasone and
Salmeterol
2- Start Salmeterol (50mcg)
1*2 inhalation/
Tiotropium (Spiriva) 18mcg
1X1 inhalation
and Albuterol 90 mcg 1-2
puffs every 4 – 6 hours PRN
3-Clarithromycin 500 mg
PO BID for 7-14 days
4-smoking cessation plan
DC bupropion start
Nicotine RT
-improvement
symptoms
-CAT (2-3 month)
-ADRs
-Pulmonary function
test
(spirometry annualy
)
-pulse oximetry
(O2 sat )
-sputum
-Monitor other co
-morbidities (CAD)
-smoking monitoring
5/3/2017 COPD Inappropriate knowledge
The patient does not understand
important information regarding his
medications (the purpose of his or
her medication)
(Fluticasone and Salmetrol)
The patient is not instructed or does
not understand non-pharmacological
therapy
(smoking ,Vaccinations, weight,
exercise)
 Patient education and
Increase knowledge about
his medications inhaler
technique
 Decreased exacerbation risk
 Improve QOL
Non-Pharmacological
1-patient education about
medication and inhaler
technique
2-Smoking cessation
3- Flu vaccine annually and
pneumococcal vaccine
(PPSV23)
4- pulmonary rehabilitation
-medication use
inhaler technique
-Smoking cessation
program monitoring
-Frequency of upper
respiratory tract
infection sputum
production – color

20. Date Medical
condition
TRPs Goal Current
Status
Interventions Follow-up
5-3-2017 CAD IHD Unnecessary drug therapy
The patient treatment
should be stepped down
(Clopidogrel)
 Avoid adverse treatment
effects(bleeding)
Stable Pharmacological
DC Clopidogrel
Bleeding signs
Efficacy
The patient requires
additional because of
guidelines recommendation
(ACEI B-Blocker
Nitroglycerin SL )
 Prevent acute coronary syndrome and
death
 Alleviate acute symptoms of
myocardial ischemia
 Prevent recurrent symptoms of
myocardial ischemia
 Prevent progression of the disease
 Reduce complications of IHD
Start
1- ACEI (Enalapril 5 mg 1*1 )
2-B-Blocker (bisoprolol 5 mg 1*1 )
3-Nitrpglycerin
.3-.4 mg SL PRN
Lipid profile
Kidney fnction k
level
ECG
O2 sat
Inappropriate knowledge
The patient is not instructed
or does not understand non-
pharmacological therapy
(smoking ,Vaccinations,
weight, exercise)
 Patient education and Increase
knowledge about his medications
Non-pharmacological
1-Smoking cessation
2- Flu vaccine annually and
pneumococcal vaccine (PPSV23)
3- weight loss aerobic exercise
-Smoking
cessation
program
monitoring
-Frequency of
upper respiratory
tract infection
Pharmaceutical Care Plan

21. Date Medical
condition
TRPs Goal Current
Status
Interventions Follow-up
5-3-
2017
Cervical
Radiculopathy
Efficacy
Efficacy interactions issues
(aspirin ibuprofen )
D : consider therapy
modification
Severity : major
Stop DDI
Increased cardio-
protective effect of
aspirin
stable 1-DC Ibuprofen
2-Start
acetaminophen
500 mg *2 PRN
3-Avoide
provocated
activities rest
ice cervical
collar gradual
movement .
Bleeding signs
Pain
Safety
Safety interactions issues
(ibuprofen aspirin )
Safety dosage regimen
issues
(ibuprofen )
Stop DDI
Decrease risk of
bleeding
Prevent ibuprofen
ADR ( GIT bleeding
AKD CVD )
stable 1-DC Ibuprofen
2-Start
acetaminophen
500 mg *2 PRN
Pain
Pharmaceutical Care Plan

22. Smoking cessation

23. Smoking cessation cont.
 1st line pharmacotherapy for tobacco dependence :
 Vareniciline
 Bupropion sustained release
 Nicotine replacement therapy (gum – inhaler- nasal spray –lozenges- patch )
 In COPD patient the probability of sustained abstinence is higher with
Nicotine replacement therapy( combination) than sustained release
Bupropion
 In our case we give (nicotine patch 14mg *14 weeks once daily )+(nicotine
gum 2 mg one piece every 1-2 hrs )
 Reference :Pharmacotherapy principles and practice ( chapter 36 )

24. Newly FDA approved
medications for COPD

25. 1- Bevespi Aerosphere
(glycopyrrolate and
formoterol fumarate)
AstraZeneca; For the treatment of chronic
obstructive pulmonary disease, Approved April
2016

26. Bevespi Aerosphere
MECHANISM OF ACTION :
is a combination of glycopyrrolate,
an anticholinergic, and formoterol
fumarate, a long-acting beta2-
adrenergic agonist (LABA).

27. Bevespi Aerosphere
* Bevespi Aerosphere is specifically indicated for the long-
term, maintenance treatment of airflow obstruction in
patients with chronic obstructive pulmonary disease
(COPD), including chronic bronchitis and/or emphysema.
•Bevespi Aerosphere is supplied as an aerosol for oral
inhalation.
The recommended dose
• for the maintenance treatment of COPD is two inhalations
twice daily in the morning and in the evening.

28. Bevespi Aerosphere
side effects:
* Urinary tract infection
* Cough
•Bevespi Aerosphere comes with the following Black Box
warning: Long-acting beta2-adrenergic agonists (LABAs), such as
formoterol fumarate, one of the active ingredients in Bevespi
Aerosphere, increase the risk of asthma-related death.
• The safety and efficacy of Bevespi Aerosphere in patients with
asthma have not been established.
• Bevespi Aerosphere is not indicated for the treatment of
asthma.

29. Price
 The cost for Bevespi Aerosphere inhalation
aerosol (4.8 mcg-9 mcg/inh) is around $362 for a
supply of 10.7 grams

30. 2- Stiolto Respimat
(tiotropium bromide and
olodaterol)
Boehringer Ingelheim; For the maintenance of chronic
obstructive pulmonary disease, Approved May 2015

31. Stiolto Respimat
Mechanism of Action
Tiotropium is LAMA
inhibition of M3-receptors at the smooth muscle leading
to bronchodilation.
Olodaterol is (LABA).
Activation of B2 receptors in the airways results in a
stimulation of intracellular adenyl cyclase, an enzyme
that mediates the synthesis of(cAMP).
Elevated levels of cAMP induce bronchodilation
RECOMMENDED DOSE :
once-daily fixed-dose combination of tiotropium and
olodaterol.

32. Stiolto Respimat
Side Effects
*Adverse reactions associated with the use of Stiolto
Respimat may include, but are not limited to, the following:
1. - Nasopharyngitis
2. - cough
3. - Back pain

33. Price
 The cost for Stiolto Respimat inhalation aerosol (2.5 mcg-
2.5 mcg) is around $368 for a supply of 4 grams

34. 3- Utibron Neohaler
(indacaterol and
glycopyrrolate)
Novartis; For the long term, maintenance
treatment of airflow obstruction in patients
with COPD, Approved October 2015

35. Utibron Neohaler
Mechanism of Action
* Utibron Neohaler is a fixed
dose combination
of glycopyrronium bromide, a
once-daily long-acting muscarinic
antagonist, and indacaterol, a
once-daily long-acting beta-2
agonist.

36. Utibron Neohaler
* Utibron Neohaler is specifically indicated for the long
term, maintenance treatment of COPD.
•Utibron Neohaler is supplied as an inhalation powder, for
oral inhalation use.
The recommended dose
•Utibron Neohaler should be administered at the same time
of the day, (1 capsule in the morning and 1 capsule in the
evening), every day.

37. Utibron Neohaler
Side Effects
* Nasopharyngitis
* Hypertension
* Utibron Neohaler comes with a black box warning of the
potential for long-acting beta2-adrenergic agonists (LABAs)
to increase the risk of asthma-related death.

38. Price
 The cost for Utibron Neohaler inhalation capsule (15.6
mcg-27.5 mcg) is around $38 for a supply of 6 capsules

39. References
 GOLD 2017
 Pharmacotherapy principles and practice
4 edition
 Up-to-date
 AHAACC
 Drugs.com