Asthma and COPD Treatment

Special guest Lori A. Wilken, PharmD, FCCP, BCACP, NCTTP, AE-C, Clinical Assistant Professor in the Department of Pharmacy Practice at the University of Illinois, Chicago, joins us to talk about Asthma and COPD treatment.

Listen in as we discuss answers to your big questions about treatment of asthma and COPD. 

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Stephen Carek, MD, CAQSM, DipABLM, Clinical Assistant Professor of Family Medicine, Prisma Health/USC-SOMG Family Medicine Residency Program at the USC School of Medicine Greenville
• Andrea Darby Stewart, MD, Associate Director, Honor Health Family Medicine Residency Program and Clinical Professor of Family, Community & Occupational Medicine at the University of Arizona College of Medicine - Phoenix
• Craig D. Williams, PharmD, FNLA, BCPS, Clinical Professor of Pharmacy Practice at the Oregon Health and Science University

For the purposes of disclosure, Dr. Wilken reports relevant financial relationships [pulmonary] with AstraZeneca/Simpson Healthcare, OptumRx. (consultant). 

The other speakers have nothing to disclose. All relevant financial relationships have been mitigated.

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

Claim Credit

The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter and Prescriber Insights: 

• Chart: Biologics and Inhalation Medications for Asthma
• Chart: Inhaled Medications for COPD

Email us: ContactUs@trchealthcare.com.

The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

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Transcript

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00:00:07 Lori Wilken

Just talking to the patient, sometimes when we do medication reconciliation, I'll ask the patients what color their maintenance inhaler is and if they have no idea what their inhaler looks like, you know that they're not.

00:00:20 Lori Wilken

Using it like they should.

00:00:25 Andrea Darby Stewart

This is 1 area where I find it incredibly frustrating that we don't have lower priced medications available to help people do the basic life function of breathing comfortably.

00:00:36 NARRATOR

Welcome to Medication Talk, the official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, RxAdvanced, and the most trusted clinical resources.

00:00:47 NARRATOR

On today’s episode, we’ll listen in as our expert panel discusses answers to your big questions about treatment of asthma and COPD.

00:00:55 NARRATOR

Our guest today is Dr. Lori Wilken from the University of Illinois Chicago College of Pharmacy. 

00:01:01 NARRATOR

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board

00:01:06 NARRATOR

Dr. Stephen Carek from the USC School of Medicine Greenville; Dr. Andrea Darby Stewart from The University of Arizona College of Medicine - Phoenix; 

00:01:15 NARRATOR

and Dr. Craig Williams from the Oregon Health and Science University.

00:01:19 NARRATOR

This podcast is an excerpt from one of TRC’s monthly live CE webinars. Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.

00:01:34 NARRATOR

The full webinar originally aired on August 20th, 2024.

00:01:39 CE NARRATOR

And now the CE information.

00:01:43 NARRATOR

This podcast offers Continuing Education credit for pharmacists, physicians, and nurses. Please log in to your Pharmacist’s Letter or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

00:01:56 NARRATOR

For the purposes of disclosure, Dr. Wilken reports a relevant financial relationship as a consultant for AstraZeneca/Simpson Healthcare and OptumRx. 

00:02:05 NARRATOR

The other speakers you’ll hear have nothing to disclose. All relevant financial relationships have been mitigated.

00:02:12 NARRATOR

Now, let’s join TRC Editor, Dr. Sara Klockars, and start our discussion!

00:02:19 Sara Klockars

To start us off, Steven, would you mind giving us a high level overview of some of the similarities and differences between asthma and COPD?

00:02:28 Stephen Carek

So asthma COPD, common lung conditions, I think that in terms of overlap similarities, these are these are lung issues going to manifest themselves with shortness of breath, cough, wheezing for patients, they'll have some sort of exacerbation component to them where the symptoms will get worse either triggered by allergies, infections, pollutants.

00:02:44 Stephen Carek

The air.

00:02:45 Stephen Carek

Asthma's unique and then this is more of a super sensitive long airway reversible airway pathology usually seen or starts earlier in life and strongly associated with things like allergies and and also has genetic predispositions for it. While COPD is more of an irreversible airway obstruction something that progressively declines.

00:03:04 Stephen Carek

Over time, usually triggered by tobacco use and probably most common things, there are other chemicals or environmental causes that may cause progressive lung decline over time and usually presents later in life, usually as adults.

00:03:19 Sara Klockars

That is a great overview. Thank you.

00:03:21 Sara Klockars

And then another question that we had was goals. What goals are you aiming for when you're treating asthma and COPD? Andrea, would you mind tackling that one?

00:03:32 Andrea Darby Stewart

Or, you know, much like anything else with our patients. We're really looking for alignment with what their goals are. Most people want to breathe a little bit more easily, not to have symptoms on a regular basis to either have no limitations or improve their ability to exercise.

00:03:48 Andrea Darby Stewart

And in the case of both asthma and COPD, to really improve their overnight sleep, we don't want them to have episodes of poor control in the middle of the night, since we know for all of us that sleep is such an important part of our health. So can my patient run if their children go to PE or participate in their team sports without any difficulties?

00:04:09 Andrea Darby Stewart

That's great for my older patients with COPD. Are they able to play with their kids and their grandkids without having any significant limitations in terms of shortness of breath or difficulty? Can they do the things that they love to do? Gardening maybe not loving the chores, but able to do them without feeling substantial symptoms.

00:04:28 Sara Klockars

We did have a couple of questions come in about.

00:04:32 Sara Klockars

What are some of those clinical clues from patients where you suspect they may be overusing reliever meds and need an adjustment of their maintenance meds?

00:04:42 Craig Williams

I'm happy to jump in. You do have to think differently about asthma versus COPD, which is kind of a theme we have going. So it's it's less clear for COPD to kind of Andrea's point. The goal is really kind of making the patient as functional as we can and to Stevens initial kind of overview, it's really it's a.

00:05:01 Craig Williams

On the condition that doesn't ever fully resolve, whereas the goal in asthma is way to kind of normalize lung function and normalize the patient functionality. So in the setting of asthma early, ideally you're using almost no reliever. So but I think more is like days per week in asthma. That's how the guidelines.

00:05:22 Craig Williams

And outline is thinking about your asthma control and your patient. If it's more than two days a week, they use and it's not ideal control and we should think about other controllers.

00:05:32 Craig Williams

Pursuit it it's kind of less clear because if they're on good maintenance therapy and they're having frequent at home exacerbations that don't require any interventions or step up in care, it's not real good as a number of uses per day of their albuterol, their petroleum, that there's necessarily a problem as long as they're managing it.

00:05:52 Craig Williams

But I think we all have a a number in mind. Like for me, you know more than 10 uses of the day of any reliever is a problematic number, but it's there's not a clear number from the studies and to Andrew's point, it goes somewhat to the goals you have with the individual patient.

00:06:07 Sara Klockars

Excellent. Lori, would you want to chime in on anything you see in practice?

00:06:13 Lori Wilken

Yeah. For our patients that when we check their refill history and we see that they're not using their medication, if you're lucky enough, they have, you know, detector there in the clinic that will help you know that they're not using their any help corticosteroids but that's pretty.

00:06:31 Lori Wilken

The.

00:06:32 Lori Wilken

And then just talking to the patient, sometimes when we do medication reconciliation, I'll ask the patients what color their maintenance inhaler is and if they have no idea what their inhaler looks like, you know that they're not using it like they should. So a lot of times they'll tell you they're struggling with using that maintenance inhaler.

00:06:54 Sara Klockars

That's a great tip. Thank you for sharing.

00:06:58 Sara Klockars

So let's move along and dive into some of the specifics with asthma management. I was hoping Craig, would you be able to give us a high level overview of the different inhaled meds we used to treat asthma?

00:07:11 Craig Williams

Yeah. I mean, the really high level overview is there are relievers and there are controllers and pretty much everything you can kind of plug in under that the relievers and we can break down into short acting. And then as we'll talk about kind of the.

00:07:25 Craig Williams

The short acting long acting combo. But really, those are the the two. I mean we nice way to teach these medications is decide which side of the bucket you're on. One of the big differences between Soupy and asthma is that control does really work for asthma. So it's the guidelines are very quick to making sure using a controller.

00:07:46 Craig Williams

And really minimizing reliever use, whereas in COPD, it's really more kind of what combination of relievers works to make the patient symptoms as as minimal as possible.

00:07:58 Craig Williams

Well.

00:07:59 Sara Klockars

Andrea, would you mind giving us an overview of the Gina guidelines and how you approach asthma treatment starting with an adolescent or an adult?

00:08:12 Andrea Darby Stewart

Sure, absolutely. So the guidelines really do recommend that we have a clear understanding of how severe the patients asthma is. Some patients will have intermittent exacerbations and so they fall into our low step or steps one and two and they might use an as needed. Low dose inhaled corticosteroids.

00:08:32 Andrea Darby Stewart

Material combination and this is a big change.

00:08:35 Andrea Darby Stewart

Compared to what we used to do, which was give everybody an albuterol inhaler and say, give me a call if you're using it too frequently, these guidelines now recommend the use of as needed inhaled corticosteroid, and that shorter acting for better all if we have patients who are having more frequent exacerbations or by spirometry qualify for Step 3.

00:08:55 Andrea Darby Stewart

Or Step 4. Then they may need either low dose maintenance or medium dose maintenance. With that inhaled corticosteroids and formatter all combination. So they'll be taking these medications on a daily basis.

00:09:07 Andrea Darby Stewart

And then they can also use the exact same medication for their rescue inhaler for people who are brand new to asthma, this is great. They get one inhaler, which is hopefully covered by their insurance appropriately and they can carry that with them and also use it on a daily basis as a preventive for patients who have not were in our prior.

00:09:28 Andrea Darby Stewart

Type of coverage for this. Sometimes it's a little bit more challenging to get them to give up that albuterol and trust that their maintenance inhaler can be used for rescue.

00:09:36 Andrea Darby Stewart

Well, and then once we get to patients who are in that Step 5, where they're having more frequent exacerbations, they're FEV one to FEC ratio is significantly reduced, then they're going to be on a high dose combination and we might actually add an antimuscarinic agent or even a biologic. And at that point from my standpoint as a family physician, this is where I would give my pulmonary.

00:09:57 Andrea Darby Stewart

Colleagues involved in the care of the patient.

00:10:01 Sara Klockars

Excellent. Thank you. And so to point out the differences with track 2.

00:10:07 Sara Klockars

This is an alternative track and the guidelines, would you mind just reviewing what the recommendation is if someone cannot be on one of the steroid beta agonist combos?

00:10:20 

00:10:20 Andrea Darby Stewart

Yeah, absolutely. And again, that comes most of the time down to finances and availability or you know quite frankly preference and people who are comfortable with a certain type of treatment. But what we do know is that we want all of our patients to be using an inhaled corticosteroid whenever they need to use their short acting bronchodilator. And so for those patients who again have that rare.

00:10:40 Andrea Darby Stewart

Exacerbation. We do ask them to use an inhale corticosteroid along with that as needed. Short acting bronchodilator albuterol for most of our patients. So this is the more traditional approach that most of our listeners are probably familiar.

00:10:52 

00:10:54 

00:10:55 Sara Klockars

OK. Thank you. And Laurie, we specifically had a question come in about what's the role of Singulair Montelukast?

00:11:04 Lori Wilken

I think that what we see with leukotriene receptor antagonist is many years of comfort, but not a lot of efficacy. So when the medication is viewed as safe, then we see a lot of prescribing of it and when it's an oral medication, it tends to be easier to take and use.

00:11:25 Lori Wilken

And we see it's approved for a wide variety of age groups. So you see a lot of use of that. But in practice, I would say it's efficacy is lacking unless somebody has allergy symptoms, then the allergists tend to add it on and it tends to help with allergies and asthma.

00:11:38 Craig Williams

Mm-hmm.

00:11:45 Craig Williams

Yeah. If I can just add briefly, they will see Luca trying antagonist.

00:11:50 Craig Williams

For patients having a lot of trouble with inhalers, what we find and the guidelines kind of support that some people are responders and a lot of people are non responders. So you look at an average population and we think about just the last.

00:12:03 Craig Williams

50-60 patients we saw on average they don't work very well and we've always known the population level, they don't work as well as steroids, but some people, they do seem to work well in. So we certainly haven't thrown them out then we still keep them in mind and the NIH has them a bit more favorably placed in their guidelines.

00:12:19 Craig Williams

Then does Gina, but they still remain in our armamentarium.

00:12:24 Craig Williams

But we should be prepared to stop them if they're not working, which is the case for a lot of people.

00:12:28 Sara Klockars

Yes, thank you.

00:12:31 Sara Klockars

Andrea, how much is height really affected by inhaled steroid use, particularly in children? And should we worry about the inhaled steroids affecting heightened kids?

00:12:43 Andrea Darby Stewart

The last time I looked there was a slight reduction in fate velocity in kids that were on chronic inhaled corticosteroids. That was resolved as they hit adolescents or when they stopped the inhaled corticosteroids. But I would love it if Craig or Laurie would chime in.

00:12:58 Andrea Darby Stewart

With the most recent updates.

00:13:01 Craig Williams

Yeah. So that's basically still the case and we'll probably never have any better data than we already have from an old study that did a pretty good job looking at this and that was the case, so.

00:13:11 Craig Williams

So for the controlled asthma has its own effects on everything in developing children. So we certainly use steroids if we need to, but it's fair that they are not quite as prominently placed in kids as they are in adults for that reason. But yeah, slightly slowed velocity during the time of use, but they seem to catch up later and does not affect their end height.

00:13:32 Craig Williams

After puberty.

00:13:34 Sara Klockars

Thank you. We also had a subscriber ask. I noticed primatene mist was not in the guidance at all. Why should we ever recommend OTC Primatene missed? I think some of our pharmacists are probably getting this question a lot since it's on the shelves and the pharmacies.

00:13:50 Lori Wilken

Yeah, we were shocked that it got put back on the shelf. Everybody was in an uproar. As you all know, it can speed up an electron, so it's not selective and we can have cardiovascular side effects.

00:14:03 Lori Wilken

But I was looking at a labeling of the primate team myths and I really like how the angular is labeled as far as compared to our regular.

00:14:14 Lori Wilken

Actual instructions listed on the flight and I.

00:14:18 Craig Williams

Yeah, it's just a terrible drug there.

00:14:20 Craig Williams

That's the Ultra short acting albuterol. So we use it as one of them. We're teaching the pharmacy student say if anyone brings us up to your counter, it's a great point to say what are you using this for and do you have a provider because it's it is out of the guidelines for a good reason and ideally wouldn't even still be available. And there's a second product.

00:14:38 Craig Williams

I think asthma nephrin is the other branded name for it.

00:14:42 Craig Williams

But yeah, not a good therapy at all.

00:14:45 Sara Klockars

Super helpful for our listeners. Thank you. I'm going to jump us over to COPD treatment and answer some questions here.

00:14:53 Sara Klockars

Steven, would you mind giving us an overview of the different types of inhaled meds to treat COPD?

00:15:01 Stephen Carek

Yeah, I'd be happy to. And in terms of COPD treatment at things Craig alluded to with similar overlap with asthma, there's long acting and they're short acting medications. We still have our short acting bronchodilators since our albuterol.

00:15:13 Stephen Carek

We also introduced this category of short acting muscarinic antagonists things like hypertrophy. Umm, that can help alleviate some of that bronchoconstriction that may be associated with COPD. We also still use our long acting beta agonists and then also the category of long acting and muscular and it can't tag it. It seems like geotropic and again trying to just provide more prolonged really for that Bronco restriction and hopefully alleviate some of their symptoms.

00:15:35 Stephen Carek

Our inhaled cortico steroids, although maybe not used as universally as an asthma still in the right patient right population, may have some anti-inflammatory effect that may help alleviate some of those symptoms and help our patients manage those symptoms with COPD. And these all come in various combination forms as well.

00:15:51 Sara Klockars

Thank you and.

00:15:53 Sara Klockars

Lori, would you mind giving us an overview on how to treat COPD initially just pointing out some of those differences from asthma?

00:16:05 Lori Wilken

Sure, I think the big point to remember with the COPD patients is.

00:16:10 Lori Wilken

The antimuscarinic component, so using that long acting muscarinic antagonist, that's the big difference compared to using inhaled corticosteroids and asthma.

00:16:22 Lori Wilken

And when we're first starting out, if they're seeing in general medicine or family medicine, they're probably not having a lot of symptoms yet. They're starting to complain about it. So any of the bronchodilators would be an option, although the long acting are more convenient. But when they start to have more symptoms, that's when we're trying to.

00:16:44 Lori Wilken

Combined, the long acting muscarinic antagonist with the long acting beta agonist to get more bronchodilation and that's when the combination products really are helpful.

00:16:56 

00:16:57 Lori Wilken

And then once the patient starts to have exacerbation, so we typically look for Prednisone used in the past year if they've had.

00:17:07 Lori Wilken

Two exacerbations, or two Prednisone births in the past year, or one hospitalization that was related to COPD, that's when we're really making sure that they're on combination therapy and then possibly adding on an inhaled cortico steroid to help decrease those exacerbation. If they have higher ethanol.

00:17:28 Lori Wilken

So.

00:17:30 Sara Klockars

That leads us right into what's the role of inhaled steroids. Andrea, would you want to tackle that one?

00:17:36 Andrea Darby Stewart

Absolutely. This has changed just a tiny bit with the last gold revision. And basically if a patient has a history of being hospitalized for COPD or they've had two or more exacerbations in the last year on Max meds, that means the patients been adherent to their meds, they've been taking them appropriately. You know that they're actually using the inhalers.

00:17:57 Andrea Darby Stewart

Appropriately or if their blood eosinophils are more than 300, then we should be adding an inhaled corticosteroid to their llama and lava.

00:18:06 Andrea Darby Stewart

If the patient has more than €100 sinophiles, you can consider adding that, particularly if they're at higher risk for exacerbation. But we know that inhaled corticosteroids may increase the risk for pneumonia. So if they have a repeated bacterial pneumonia history of a mycobacterial infection, then we would want to avoid use of inhaled.

00:18:26 Andrea Darby Stewart

Corticosteroids in these patients, so there's a lot of if vens that occur when you're thinking about adding an inhaled corticosteroid to your COPD patient.

00:18:36 Lori Wilken

If I could just jump in real quickly.

00:18:39 Lori Wilken

I know the guidelines have had the SNFL's listed here for checking for inhaled cortico steroid use for the past couple of updates. I'm still seeing even in the pulmonary clinic or pulmonologist just now getting up to speed with checking the NFL and not knowing really.

00:18:59 Lori Wilken

You know, with the cut cut off, point is.

00:19:02 Lori Wilken

I feel like if a patient is having exacerbations that are related to a hospitalization or if they have a really low FEV one, that they will lead towards using an inhaled corticosteroid. But of course, if the patient has pneumonia from being on triple therapy, then they'll.

00:19:23 Lori Wilken

Start to step back away from it.

00:19:26 Sara Klockars

Thank you for sharing that. Can you clarify for our listeners Lori, when it's OK to use LABA monotherapy?

00:19:35 Lori Wilken

Yeah, the old guidelines still list labas as an option for our patient, and they really haven't shown. They haven't increased cardiovascular concern in our COPD patient.

00:19:49 Lori Wilken

But I'll tell you from practice a lot of times there's confusion with whether the patient has pure COPD versus having a little bit of asthma component. And I see a fear from our doctors from using lava alone just because they don't want that down regulation.

00:20:08 Lori Wilken

Of the receptors and the patients not responding to a quick reliever. So the only time I see a lobby use the loan and other people jump into is when we can't get a llama lava or if something's not covered on their insurance.

00:20:26 Lori Wilken

Or if a patient had a side effect from a llama that they're still using a llama.

00:20:34 Craig Williams

You know that's there that if you can get a llama, there's really no reason to use a llama ahead of it. But if it's definitely a supply patient, it's absolutely safe. So it's in the guidelines still is an option, and those cardiovascular concerns.

00:20:47 Craig Williams

Just did not play out when kind of prospective studies were done. There was some early data doing a lot of retrospective mining of health systems, but it is safe. But Jenny Lamas are preferred and might have a bit more persistence of benefit. Llamas might win by a nose in many patients, but it is safe if it is a suite.

00:21:06 Craig Williams

Patient a very unlike asthma.

00:21:09 Sara Klockars

Thank you. Another audience question. It seems like most patients with asthma should have a steroid but not with COPD. So how do you treat patients with both COPD and asthma? And Lori, you kind of commented on this, but could you expand on this a bit?

00:21:26 Lori Wilken

If a patient has asthma, even if they have asthma and COPD, they should be on an inhaled corticosteroid, it might be a lower dose than help corticosteroids. But oftentimes these patients are more severe and we're using triple therapy for them.

00:21:43 Lori Wilken

I always tell the students if the patient has asthma, you want to make sure that they're on an inhaled corticosteroid.

00:21:49 Craig Williams

And I'll also add, Sarah, that we've debated this topic in the literature for a while, and that goes by different acronyms as combined stupid asthma condition. It it's fortunately probably fairly uncommon. I mean your classic asthmatic 25 year old with allergies to toggle danders very different than your classic soupy patient, 65 years old, the history of smoking but.

00:22:07 Sara Klockars

MHM.

00:22:10 Craig Williams

There's no question patients with mild asthma can age into developing COPD, and yeah, it's probably more that some COPD.

00:22:18 Craig Williams

Has a very reversible asthmatic like component that benefits from steroids. And as we talked about, the goal guidelines are trying to throw out for like 30 years. Who really benefits from steroids that just has to see what we did and we used to say it's this asmatic component, stupid patient and so. But but fortune, our practice usually they're they're pretty distinct.

00:22:38 Craig Williams

Patients. But yeah, if there's asthma present, steroids much more favored. And you really need to be honest. Steroid for your asthma.

00:22:46 Sara Klockars

Thank you for clarifying. So I want to move us along to talk about correct use of inhalers since about 70 to 80% of patients do not use their inhaler correctly. So what are some common mistakes you see in practice, Andrea, when you are?

00:23:07 Sara Klockars

By talking with your patients with asthma or COPD.

00:23:10 Andrea Darby Stewart

While I still have patients popping the entire inhaler in their mouth, which is.

00:23:15 Andrea Darby Stewart

You know, probably not the best when they're using their short acting inhaler or they don't put it far enough in their if they're using that technique correctly, they're actually just putting it right up against their teeth. That's not great. They're taking a quick inhale versus a kind of a nice long, deep inhale. They're not shaking the inhaler. They have no idea.

00:23:37 Andrea Darby Stewart

How to look at the number of counts on the back of the inhaler, which is a really important thing, particularly for our patients with asthma when we know that they do.

00:23:46 Andrea Darby Stewart

Need to have that rescue inhaler immediately available if they have a severe exacerbation and a couple of my teenage patients, let me know that when they're in bed they just kind of lay over on their side and take a puff off the inhaler while they're laying down at night. If they have an exacerbation then so just really trying to help. We've got some great handouts.

00:24:06 Andrea Darby Stewart

We do some directed training with patients for appropriate inhaler use and hopefully that improves everything for them.

00:24:16 Sara Klockars

Thank you. And so in addition to providing handouts, what are some other things we can do to help patients use their inhalers correctly? Lori, what are things you do in practice?

00:24:28 Lori Wilken

I have a lot of fun going into the rooms and counseling patients with inhalers. I get to see all those fun things that they're doing incorrectly.

00:24:36 Lori Wilken

To.

00:24:38 Lori Wilken

One thing that I've used over the years is a standardized checklist. I saw somebody doing this for a clinical study, but then when I started using it in practice, I found that and with much dreamline a lot better. Also, the teach back method, so making sure that the patients are able to.

00:24:59 Lori Wilken

Each back what I just taught them, it's really important because that oftentimes would think, Oh yeah, they understand. And then when they keep back and see the things that they still didn't.

00:25:09 Lori Wilken

Yeah.

00:25:10 Lori Wilken

And the third thing that I like to use is videos, so I will use the videos from the manufacturers website, but I also use use inhaler.com website American Loan Association a lot of different organizations have really come and people we've gone well especially.

00:25:30 Lori Wilken

If it's in another language or written instructions and sound effects it seems.

00:25:38 Lori Wilken

To go along.

00:25:40 Lori Wilken

With the teaching and checklist really well.

00:25:45 Craig Williams

I'll just add briefly, Sarah, that MDIS are really difficult to use well. Dpis think are easier to use as intended. So, and I think manufacturers are picking up on this a lot more dry powder devices coming out. And actually I probably prefer those for most patients over an MDI and MDI really should use with a spacer to really get optimal delivery and that's.

00:26:05 Sara Klockars

MHM.

00:26:07 Craig Williams

To ask someone to carry your spacer with them, maybe Andrew can give a spacer have at the bedside of your teenage patient. Maybe to but but using a spacer makes it so much easier, but that's just to compliance with those. Is just terrible so but but dry powder inhalers you get rid of all that issue of trying to time your inhalation with the air isolation of the medicine. You just give that strong inhalation.

00:26:27 Craig Williams

On the device. So I really like the dry pattern options when they're available.

00:26:34 Sara Klockars

Thank you. And Steven, do you have any comments on tailoring inhalers to different patient populations?

00:26:41 Stephen Carek

Yeah, kind of go along with the group has said, I mean really assessing for adherence the best inhalers, the one that goes on a regular basis. Now what too is there's still a lot of confusion about for patients and understanding which one is their inhaler and which one is their controller all the time in clinical practice using a controller for or using them for the other purpose.

00:27:00 Stephen Carek

And so really, providing that education and guidance and making sure they understand the indications and timing for when to use certain inhalers.

00:27:08 Sara Klockars

Good point.

00:27:10 Sara Klockars

We had a couple of questions about nebulizers. So our nebulizer is more effective. What's the difference between nebs and inhalers? Lori, would you want to comment for our listeners on that question?

00:27:24 Lori Wilken

Sure. I think patient be the nebulizer used in the emergency room or the hospital.

00:27:30 Lori Wilken

And they tend to think that the nebulizer is more effective, not realizing that the dosing that's in the inhalation solution is so much higher than that of half of the medication. But with COVID, I think we really went by the wayside and started using a lot more meter dose inhalers with spacers, so.

00:27:51 Lori Wilken

We did some training to get some of our patients away from using nebulizer so much so it's not necessarily more effective if somebody has trouble with technique. I think then it is a good option for patients to still have that option of using a nebulized medication if.

00:28:09 Lori Wilken

They're not able to use an inhaler, crafty or they are else like this or something like that. That is with their use.

00:28:18 Craig Williams

You know, say, and generally many more adverse effects because the dose is so much higher and much higher dose you swallow and some of these drugs are fairly bioavailable, including albuterol. So nebulizers generally recommended when someone cannot use an inhaler device.

00:28:34 Sara Klockars

Thank you.

00:28:35 Sara Klockars

Deal. We have a ton of questions coming in from the audience. Couple are coming in about beta blockers. So, Craig, I was wondering if you could comment on this. To what extent can a beta blocker use impact patients with asthma or COPD? I know this question comes up quite a bit.

00:28:57 Craig Williams

It does, yeah. Unfortunately, it comes up enough and for long enough time we have pretty good data that we should avoid non selective beta blockers. So classically, when I was in school that was Propranolol. These days Carvedilol is the one to keep in mind. So probably a bigger issue with our patients with asthma than with stupidity. But if you have an obstructive.

00:29:17 Craig Williams

Belong to these. We should generally avoid non selective beta blockers and these days that really is carvedilol in practice. So, but if you have a cardiac indication for beta log or a cardioselective agent is absolutely OK and will not worsen pulmonary outcomes. So it's a good question and it does come up.

00:29:36 Sara Klockars

Thank you. We also have a question about the incidence of thrush with inhaled steroids. Lori, would you want to comment on how often you see that in practice?

00:29:47 Lori Wilken

Here and I just wanted to add to Craig's comments about the beta blockers too. Don't forget about the eye drops. That's something that I see a lot in our COPD patients and with glaucoma. So making sure that they get switched off with something that's not going to cause problems with their breathing too. With the eye drops, but the thrush.

00:30:08 Lori Wilken

I see once in a while in our path.

00:30:11 Lori Wilken

They're not rinsing their mouth or they're not using a spacer. Sometimes we have to lower the dose of the inhaled corticosteroid or switch to a different agent, but yes, that could make somebody non adherent because they don't want that brush or that side effect.

00:30:29 Craig Williams

You know, it's really quite minimal with a spacer to use a space device. I really found you don't really need to rinse your mouth afterwards because it's just so little of it. Deposits in the oral pharynx. So really depending on technique and patient use.

00:30:46 Sara Klockars

Lori, could you just briefly discuss what Mark is and if there is an increased incidence of thrush with mark since you can use the inhaler a lot more often?

00:30:59 Lori Wilken

That's an interesting question. So Mark is maintenance and reliever therapy. It's when our patients are needing an inhaler on a daily basis, usually we use.

00:31:11 Lori Wilken

IPS for motor all as the maintenance and it will be usually once or twice a day, and then they'll also use it as their reliever. So it's really nice if you're able to get enough of the inhaler covers for them to use for both maintenance and reliever, and then the rinsing of the mouth interesting on the the studies when they use.

00:31:32 Lori Wilken

ICS for Motorola. As a reliever, they didn't have the patient rinse their mouth in the studies and they didn't see an increased risk of rush. So I still tend to tell them to rinse and spit. I guess it's part of my education point.

00:31:50 Sara Klockars

Thank you. Question for Andrea or Stephen. So how do you handle calls from pharmacies when certain meds are not covered and how do you switch between inhalers if needed?

00:32:03 Stephen Carek

Gosh, there's there's a few options that we have and I think one thing that I've seen those in the past few years is that the emars can sometimes be a pretty helpful tool at the point of the patient.

00:32:12 Stephen Carek

Chair.

00:32:13 Stephen Carek

At least acknowledging which medications, especially combined inhalers, may be covered by patients insurance. So that's one thing that at least has evolved for the past several years, and the 2nd 2 is always just trying to go towards generic medications. This tend to be at least the most affordable, and then some of the other prescribing practices of 30 days supply versus 90 days supply and that may hopefully provide easier coverage for patients as well.

00:32:35 Stephen Carek

And I know if you have any other suggestions too.

00:32:38 Andrea Darby Stewart

No, I think you know, as long as our ER's are updated, that's helpful. The challenge of course is that a lot of these inhalers are not covered, not available by alternative means. And so talking with the pharmacist or asking my MA colleagues to ask the pharmacist what might be covered, knowing where the formulary is available online.

00:32:58 Andrea Darby Stewart

Doing a little bit of digging to see what I might have available as well are really just the ways that we can help mitigate this. This is 1 area where I find it incredibly frustrating that we don't have lower priced medications available to help people do the basic life function of breathing comfortably.

00:33:16 Stephen Carek

You know, could be frustrating too, as that felt change suddenly too,

00:33:18 Stephen Carek

as you have a patient really well controlled for a period of sometimes years and they either maybe they switch on to Medicare or they switch insurances and then have to just go back and almost like you're starting over again with a different inhaler. And there's now a cost barrier for them to just have a better quality of life because of the the disease process.

00:33:35 Andrea Darby Stewart

Every January.

00:33:37 Sara Klockars

Lori, do you have any tips from your clinics and how you help your patients afford their inhalers?

00:33:43 Lori Wilken

No, we did the exact same thing. It's a game of playing. Yep, switching around and our everybody gets frustrated.

00:33:44 Sara Klockars

OK. Mm-hmm.

00:33:53 Craig Williams

Mainly the the only upside is, you know, llamas are pretty interchangeable. Other llamas and lamas, other labas. But yeah, it's a frustrating lack mole game to have to play on the provider side and very frustrating for patients and very frustrating for pharmacists have to deal with us on the front line too, but they can be your best friend to help figure.

00:34:08 Craig Williams

Out which one is the covered agent?

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