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Australian Journal of Pharmacy : May 2008
aJPcPd CONTINUING PrOfEssIONAL dEvELOPmENT 250-500mcg), provide symptom relief and may increase exercise capacity. The two classes of inhaled bronchodilators—selective ß2 agonists and anticholinergic agents—target airway smooth muscle contraction, which is one cause of the physiological and functional deficits in COPD. The duration of action of short- agonists. The combination of ß2 agonists and anticholinergics, acting inhaled anticholinergic agents is greater than that of short-acting ß2 may be more effective and better tolerated, than higher doses of either agent used alone. All bronchodilators have been shown to improve exercise capacity. Nebulisers are not recommended for routine use in stable disease.3 If there is response to short- acting treatment, consider substituting with long-acting treatment. For example salmeterol 25–90mcg up to 100mcg twice daily in more severe cases, or eformoterol 6–12mcg up to 48mcg maximum daily dose. Regular treatment with long-acting ß2 agonists is more effective and convenient than treatment with short-acting bronchodilators (evidence level 1), and is associated with improved quality of life (evidence level 2); although the review did not show an improvement in forced expiratory volume in one second (FEV1 )1 . Long-acting beta-agonists (LABAs, eg. salmeterol and eformoterol) provide bronchodilation for about 12 hours and are used in moderate-to-severe COPD. Combinations of inhaled corticosteroid plus a LABA The TORCH study showed the benefits of using combinations of LABAs with inhaled corticosteroid inhalers.8,9,10,11 The trial showed that the reduction in death from all causes among patients with COPD in the combination-therapy group did not quite reach the predetermined level of statistical significance (p=0.052 obtained: p=0.050 required). But there were significant benefits in all other outcomes among these patients and, consequently. this therapy has been approved and funded by the Pharmaceutical Benefits Scheme (PBS). tiotropium (18mcg inhaled once daily), available as Spiriva in a Handihaler—an inhaled anticholinergic agent—has a duration of effect of more than 24 hours and is used once-daily. It is subsidised under the PBS for use in patients with COPD. Compared with placebo and regular ipratropium, it reduces dyspnoea and exacerbation rate and improves quality of life.6 It also decreases exertional dyspnoea and increases endurance, by reducing hyperinflation (evidence level 1).1 theophylline is rarely used because of its narrow therapeutic index and potential for significant side effects. However, some patients find it beneficial. Theophylline may have an anti-inflammatory effect and is used when other treatments have failed to control symptoms9 The long-term use of systemic corticosteroids in COPD is not recommended. There is no evidence to support the long-term use of oral steroids at daily doses less than 10–15mg prednisolone, although, there is some evidence that higher doses above 30mg improves lung function over a short period. However, there are concerns about adverse effects, particularly in older persons. reduction of osteoporosis risk factors should also be considered. Doses greater than 1000mcg per day are associated with biochemical markers of increased bone turnover. It is, therefore, wise in patients taking inhaled corticosteroids to check bone mineral density, serum calcium and vitamin D3 status. education COUNsELLING CA s EBOOK Treatment with agents such as bisphosphonates, or strontium, may be required even prior to fractures. Routine use of prophylactic antibiotics, antitussives, vasodilators and respiratory stimulants is not recommended on the basis of current evidence.10 Speech therapists are often invaluable in providing techniques to assist swallowing. As with asthma, inhaler devices must be explained and demonstrated for patients to achieve optimal benefit. Older persons, especially those with cognitive deficits, may have difficulty with some devices. In any pharmacy setting, pharmacists should ensure that their patients know how to use their inhaler devices. Home medicines reviews (HMRs) provide an ideal, non- threatening opportunity for checking technique and recommending the most appropriate device. 3. imProve function oxygen therapy: Long-term, continuous (longer than 16 hours per day) oxygen therapy to treat chronic hypoxaemia prolongs survival of patients with COPD, presumably by reducing pulmonary hypertension. Non-invasive positive pressure ventilation in combination with oxygen therapy is being trialled to determine beneficial effects with COPD patients.1 reflux: In patients with COPD, hyperinflation, coughing and the increased negative intrathoracic pressures of inspiration may predispose to reflux, especially during recumbency and sleep. ThE AUsTrALIAN jOUrNAL Of PhArmACy vOL.89 mAy 2008 79