COPD - Free CE Continuing Education online pharmacy, pharmacists

Women Beware 

The Threat of COPD 

Catherine E. Cooke, PharmD, BCPS, PAHM 

President, PosiHealth, Inc. & Clinical Associate 

Professor, University of Maryland School of Pharmacy 

Supported by an education grant from Boehringer Ingelheim

Women Beware 


Speaker: Catherine Cooke attained her Bachelor in Pharmacy from the University of Iowa and then 

went on to receive her Pharm.D. from the Medical University of South Carolina. Subsequently, she 

completed a specialty residency in Ambulatory Care/Managed Care through the Philadelphia College of 

Pharmacy and Science. After post-graduate training, Dr. Cooke served as a full-time Assistant 

Professor at the University of Maryland School of Pharmacy where she became a Board Certified 

Pharmacotherapy Specialist. Currently, she is an Independent Consultant working in health care quality 

and research. In addition, she provides clinical pharmacy services such as hypertension, dyslipidemia 

and smoking cessation management to patients in Maryland. Her main research interests are in the 

areas of cardiovascular pharmacotherapeutics and pharmacy services in the managed care 

environment with specific interest in discrepancies in health care based on sex or ethnicity. 

Speaker Disclosure: Dr. Cooke has no actual or potential conflicts of interest in relation to this program 

Supported by an education grant from Boehringer Ingelheim 

PharmCon is accredited by the Accreditation Council for Pharmacy Education as a provider of 

continuing pharmacy education

Women Beware 


Accreditation: 

Pharmacists 798-000-09-028-L01-P 

Pharmacy Technicians 798-000-09-028-L01-T 

Target Audience: Pharmacists & Technicians 

CE Credits: 

1.0 Continuing Education Credit or 0.1 CEU for 

pharmacists/technicians 

Expiration Date: 05/27/2012 

Program Overview: Women have made a good deal of welcome progress in the last several decades, but at least one 

advance is unwanted: chronic obstructive pulmonary disease (COPD) is on the rise in women in prevalence, morbidity and 

mortality. By 2000, the number of women dying from COPD surpassed the number of men. But the rising number of cases in 

women has not been matched by medical understanding of the disease's apparent gender-bias. This program will increase 

the awareness of COPD in women. The program will focus on the pharmacists role in identifying patients with COPD (women 

in particular), reducing the risk factors for developing COPD (such as smoking cessation), and managing the disease. 

Objectives: 

•Review the etiology and epidemiology of chronic obstructive pulmonary disease (COPD) in women. 

•Identify the impact of COPD on women and the differences in how the disease manifests itself in women compared to men. 

•Provide an update on the efficacy, safety, and role of available treatments in the management of COPD. 

•Describe how pharmacist’s can play a critical role in COPD identification, management and education (particularly with 

women). 

Supported by an education grant from Boehringer Ingelheim 

PharmCon is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy 

education

Learning Objectives 

• REVIEW the etiology and epidemiology of chronic 

obstructive pulmonary disease (COPD) in women. 

• IDENTIFY the impact of COPD on women and the 

differences in how the disease manifests itself in 

women compared to men. 

• PROVIDE an update on the efficacy, safety, and role 

of available treatments to manage COPD. 

• DESCRIBE how pharmacist’s can play a critical role 

in COPD identification, management and education 

(particularly with women).

Chronic obstructive pulmonary 

disease (COPD) 

• Characterized by airflow limitation 

• Not fully reversible 

• Usually progressive 

• Used to be looked upon as 2 diseases –chronic 

bronchitis and emphysema– but usually 

conditions coexist 

• Chronic bronchitis 

• Bronchial tubes are inflamed and eventually scarred 

• Emphysema 

• Alveoli are irreversibly damaged and lose elasticity 

1. Rennard SI. COPD: overview of definitions, epidemiology, and factors influencing its development. Chest 1998;113(Suppl 4):235‐‐41s.

COPD 

Asthma 

Age of onset Usually >40 years Any age (usually 

< 40 years) 

Smoking History 

Symptom 

Pattern 

Airway 

Reversibility 

Steroid response 

in stable disease 

Usually > 20 packyears 

Usually chronic, 

slowly progressive 

Partially reversible 

Unusual (~15% ‐ 

20%) 

Unrelated 

Varies day by day 

Nocturnal/early 

morning 

Largely reversible 

Present

Clinical Presentation of COPD 

• Symptoms 

• Chronic cough 

• Sputum production 

• Shortness of breath leading to chronic fatigue, decreased 

exercise capacity and increased respiratory exacerbations 

• Consequences 

• Respiratory failure 

• Cor pulmonale (right sided heart failure) 

• Respiratory exacerbations become life‐threatening

Spirometry 

•Lung function reported as percent of 

predicted values for 

a normal population 

•Terminology 

• FEV 1 = forced expiratory volume in 1 second 

• FVC = forced vital capacity

COPD – Defining Characteristics 

Spirometric diagnostic criteria 

•Reduced forced expiratory volume in 1 second 

FEV 1 < 80% 

•Reduced ratio of FEV 1 to FVC 

FEV 1 /FVC < 70%

Spirometry: Volume/Time Curve 

FEV 1 FVC FEV 1 / FVC 

Normal 4.15 

5.2 > 80% 


2.35 3.9 < 70% 

1 

2 

FEV 1 

Liters 

3 

4 

FEV 1 


FVC 

5 

Normal 

FVC 

1 2 3 4 5 6 

Seconds

Diagnosis of COPD in Women 

80 

70 

60 

% 

Diagnosed 

50 

40 

30 

20 

10 

0 

Clinical presentation 

Female case 

Male case 

Spirometry

Diagnosis of COPD in Women 

• Spirometry 

• Primary care physicians underutilize spirometry 

• Women less likely to receive referrals to 

specialists than men 

• Study: Confronting COPD Survey 

• Women less likely to have spirometry than men 

(OR 0.84; 95% CI 0.72‐0.98)

• Estimated 24 million adults with COPD in US 

• COPD ‐ 4 th leading cause of death in the US 1 

• Hospitalization: 

• Hospitalization rates greater for women than men since 1993 

• Mortality –worse in women 

1. National Center for Health Statistics. Deaths: final data for 1999. Hyattsville, MD: U.S. Department of Health 

and Human Services, Centers for Disease Control and Prevention. National Vital Statistics Report 2001;49:1– 

116. 

2. American Lung Association Epidemiology and Statistics Unit Research and Program Services. Trends in 

COPD(Chronic Bronchitis and Emphysema); Morbidity and Mortality. American Lung Association Website. 

http://lungusa.org. Accessed march 14 th , 2009.

Number Deaths x 1000 

70 

60 

50 

40 

30 

20 

10 

0 

Men 

Women 

1980 1985 1990 1995 2000 

US Centers for Disease Control and Prevention, 2002

• Tobacco use is the #1 cause of COPD 1 

• 75% of deaths from COPD resulted from 

smoking in 2005 

• Cigarette smokers vs. nonsmokers 2 

• Greater annual decrease in FEV1 

• More respiratory symptoms 

• Higher death rates 

1. Centers for Disease Control and Prevention (CDC). Deaths from chronic obstructive pulmonary disease‐‐United States, 2000‐2005. [Journal Article] 

MMWR ‐ Morbidity & Mortality Weekly Report. 57(45):1229‐32, 2008 Nov 14. 

2. American Lung Association Epidemiology and Statistics Unit Research and Program Services. Trends in COPD(Chronic Bronchitis and Emphysema); 

Morbidity and Mortality. American Lung Association Website. http://lungusa.org. Accessed march 14 th , 2009.

Women more susceptible to smoke? 

• Meta‐analysis: Women who smoke had 

significantly faster annual decline in FEV1% 

predicted with increasing age vs. men who 

smoke 

• Lung Health Study 

• Increase in # of cigarettes resulted in larger 

decline in FEV1 than men 

• Why?

• Genetic – severe heredity deficiency of 

alpha‐1 antitrypsin 

• Occupational –dust and chemicals 

• Pollution – indoor (biomass cooking) and 

outdoor (urban pollution) 

• Infection– severe childhood respiratory 

infection 

• Women who smoke during pregnancy 

decrease lung growth in utero 

1. American Lung Association Epidemiology and Statistics Unit Research and Program Services. Trends in COPD (Chronic Bronchitis and Emphysema): Morbidity and Mortality. American Lung 

Association Website. http://lungusa.org. Accessed March 14 th , 2009.

GOLD –Global Initiative for 

Chronic Obstructive Lung 

Disease 1 

• US National Heart, Lung and 

Blood Institute and World Health 

Organization joint committee 

• First published in 2001 

• Last revision published 2008 

• Covers diagnosis, management 

and prevention 

• Does not differentiate diagnosis 

and management between men 

and women 

1. National Heart, Lung, and Blood Institute and World Health Organization. Global initiative for chronic obstructive lung disease: global strategy for diagnosis, management, and prevention of 

chronic obstructive pulmonary disease. 2008 update. Available at: www.goldcopd.com. Accessed March 15 th ,2009.

Treatment Pathway

I: Mild COPD 

•FEV1/FVC < 70% 

•FEV1 >= 80% predicted 

II: Moderate COPD 

•FEV1/FVC < 70% 

•50%

Non Pharmacologic 

Therapy

Smoking Cessation

Vaccines 

• Flu: Annual influenza vaccine 

• Pneumococcal polysaccharide vaccine 

▪ Age 65 or older 

▪

Pharmacotherapy

• Central to symptomatic management 

• PRN or scheduled based on severity 

• Inhaled route preferred – fewer adverse effects 

• Includes: β2‐ agonists, anticholinergics and 

methylxanthines 

• All increase exercise capacity 

• Long‐acting forms more effective and convenient

Medication 

Class 

Bronchodilator- 

Short acting B2- 

agonist 

Class Side 

Effects: 

dry mouth, irritated 

throat, trembling, 

nervousness, 

dizziness, 

headache, 

palpitations, 

nausea, vomiting 

Brand Generic Availability Dosage 

Form 

Proventil Albuterol Brand only Inhaler No -asthma, 

bronchitis 

FDA approval Directions 

2 inhalationsevery 4—6 

hours 

Ventolin Albuterol Brand only Inhaler No -asthma 2 inhalations every 4—6 

hours 

Proair Albuterol Brand only Inhaler No -asthma 2 inhalations every 4—6 

hours 

Xopenex levalbuterol Brand only Inhaler No - asthma 2 inhalations every 4—6 

hours 

Maxair Pirbuterol Brand only Inhaler Yes 2 inhalations every 4—6 

hours 

Brethine Terbutaline Generic only Tablets Yes, also asthma 5 mg PO three times daily 

Alupent Metaproterenol Generic only nebulizing 

solution 

Accuneb Albuterol solution Generic only nebulizing 

solution 

Yes 0.2—0.3 ml of 5% (10—15 

mg) solution, diluted in 2.5— 

3 ml of 1/2 NS, NS, or other 

diluents or, 2.5 ml of 0.4— 

0.6% solution (10—15 mg). 

Doses may be repeated 3—4 

times per day 

No -asthma, 

bronchitis 

2.5—5 mg initially every 20 

minutes for 3 doses, then 

2.5—10 mg every 1—4 

hours as needed 

1. Micromedex® Healthcare Series [intranet database]. Version 5.1. Greenwood Village, Colo: Thomson Healthcare. Available at: http://www.thomsonhc.com.ezproxy.samford.edu/ 

home/dispatch. Accessed March 18 2009.

Medication 

Class 


Form 

FDA 

approval 

Directions 

Bronchodilator- 

Long acting B2- 

agonist 

Foradil Formoterol Brand only Aerolizer Yes, also asthmaInhale 12 mcg (contents 

of one capsule) every 12 

hours using the Aerolizer 

Serevent Salmeterol Brand only Diskus Yes, also asthma50 mcg (1 oral inhalation) 

of salmeterol twice daily 

Class Side Effects: 

dry mouth, irritated 

throat, trembling, Perforomist Formoterol Brand only Nebulizing 

nervousness, 

solution 

dizziness, 

headache, 

palpitations, 

nausea, vomiting 

Yes, also asthmaOne 20 mcg unit dose 

vial administered by 

nebulization twice daily in 

the morning and evening 



Medication 

Class 


Form 

FDA 

approval 

Directions 

Anitcholinergics- 

Short and long 

acting 

Atrovent ipratropium Brand only Inhaler Yes, also asthma 2 sprays (18 mcg/spray) 

3—4 times per day 

Class Side 

Effects: 

Dry mouth, blurred 

vision, 

constipation, runny 

nose, irritated 

throat, runny nose, 

Spiriva tiotropium Brand only Handihaler Yes 18 mcg once per day via 

oral inhalation 

Ipitropiuim 

solution 

ipratropium Generic only Nebulizing 

solution 

Yes, also asthma 500 mcg (1 unit dose vial) 

3—4 times per day via 

oral nebulization 



AntiCholinergics & CV Risk? 

• Meta‐Analysis to assess CV risks associated with >30 day use of 

ipratropium and tiotropium vs. control in patients with COPD 

• 17 RCT with 7472 on anticholinergics and 7311 on control 

• Results: 

• Inhaled anticholinergics significantly increased: 

▪ Risk of CV death, non‐fatal MI or stroke, RR 1.58 (95% CI, 

1.21‐2.06) 

▪ MI, RR 1.53, (95% CI 1.05‐2.23) 

▪ CV death, RR 1.80 (95% CI 1.17‐2.77) 

• Stroke NOT significantly increased 

• Secondary outcome ‐ risk of all‐cause mortality NS difference 

• Need prospective RCT to accurately access CV risk

• Low dose theophylline reduces exacerbations but 

does not increase post‐bronchodilator lung function 

• Higher does are effective bronchodilators, but may 

cause toxicity 

• Theophylline Dosing 

• 150mg BID increase to 200mg BID after 3 days, 

• Then 300mg BID after 3 days or 300‐400 QD then 400‐ 

600mg QD 

• Titrate according to blood level 



Steroids 

• Regular treatment does not modify long term 

decline 

• Increases likelihood of pneumonia, does not 

decrease mortality 

• Reduce exacerbations in Severe COPD and Very 

Severe COPD FEV1

Inhaled Steroids 

Medication 

Class 


Form 

FDA 

approval 

Directions 

Inhaled 

Corticosteroids 

Qvar beclomethasone Brand only Inhaler No - asthma 40—80 mcg (1—2 sprays) 

inhaled orally twice daily 

Pulmicort budesonide Brand only Flexhaler No - asthma 360 mcg twice daily by 

oral inhalation 

Pulmicort 

Respules 

budesonide Brand/Generic Nebulizing 

solution 

No - asthma For children: 0.5 mg/day 

inhaled via jet nebulizer 

either once daily or divided 

into 2 doses 

Flovent fluticasone Brand only Diskus Yes, also asthma 1 inhalation twice daily 

Class Side 

Effects: 

dry mouth, 

hoarseness, 

throat infection, 

oral candidiasis 

Alvesco Ciclesonide Brand only Inhaler No, asthma, 

allergies 

1 inhalation twice daily 

Asmanex Brand only Twisthaler No, asthma 1 inhalation twice dialy 

Azmacort triamcinolone Brand only Inhaler No - asthma Initially, 150 mcg (2 

inhalations) PO 3—4 times 

per day or 300 mcg (4 

inhalations) PO twice 

daily. 

Aerobid flunisolide Brand only Inhaler No- asthma 2 sprays (250 mcg/spray) 

via oral inhalation twice 

daily 




Form 

FDA approval 

Directions 

Combivent albuterol/ipratropium Brand only Inhaler Yes, also asthma Inhale 2 actuations four times 

per day 

Advair salmeterol/fluticasone Brand only Diskhaler Yes, also asthma 1 inhalation twice a day 

Duoneb albuterol/ipratropium Brand/generic Nebulizing 

solution 

Yes, also asthma 

Inhale one 3 ml vial via 

nebulizer four times per day 

Symbicort budesonide/formoterol Brand only Inhaler Yes, also asthma 2 inhalations of Symbicort 

160/4.5 (160 mcg of 

budesonide and 4.5 mcg of 

formoterol per inhalation) twice 

daily 



• Inquire about and recommend spirometry 

• Smoking cessation counseling at every visit 

• Nutrition counseling 

• Preventing infections –hand washing, vaccinations 

• Recognizing exacerbations 

• Education 

• Depression and anxiety screening 

• Support groups

• Training patients to use inhalers is crucial 1 : 

1. Mourad RE, Hagerman JK. Management Strategies in Stable COPD. US Pharmacist.2009;34‐HS‐10‐HS‐18. Jan 26 2009.

66 yo woman visits PCP for a lingering cough 

after having a cold 

Subjective: 

CC: “I’ve been recovering from a cold, but the cough is 

getting worse even though my nose is not running anymore. 

Sometimes the cough is so bad that it keeps me awake 

at night.“ 

HPI: MF recovered from a cold 1 month ago, but still suffers 

from a cough with sputum. Patient has had a chronic cough 

since she quit smoking 5 years ago, but lately it is getting 

worse. Cough worsens with exercise and during the winter 

months. 

PMH: Tobacco dependence for 35 years, smoke‐free for 5 

years, HTN, Seasonal allergies



Objective: 

Medications: 

• Amlodipine 10mg PO QAM 

• HCTZ 25 mg PO QAM 

• Nasonex 2 sprays in each nostril QD during allergy season 

• Claritin D PO QD during allergy season 

PE: General‐ Overweight female coughing with clear sputum. 

VS: BP138/85, P 110, RR 22, Wt 70kg, Ht 5’4’, T 37 

degrees, O2 sat 90%



Diagnosis: 

• CXR ‐ Normal 

• Spirometry ‐ FEV1 = 0.65, FEV1/FVC= 76% (Referral to 

pulmonologist) 

Assessment: 

1) Undiagnosed Stage II moderate COPD ‐ uncontrolled 

2) HTN ‐ controlled 

3) Seasonal allergic rhinitis ‐ controlled

Stage II moderate COPD ‐ uncontrolled 

Plan: 

• Educate patient about disease and disease 

progression 

• Pharmacologic regimen: 

• Start short‐acting beta‐agonist inhaler PRN and 

tioptropium inhalation QD 

• Education patient on inhaler technique 

• Re‐evaluate in 1 month 

• Schedule for influenza (seasonal) and 

pneumococcal vaccinations

Conclusion 

• Improve diagnosis of COPD in women 

(increased suspicion, spirometry, referral to 

specialist) 

• Education: Prevention –Smoking 

• Women at higher risk 

• Management: Smoking cessation (with 

increased attention to preventing relapse) 

• Vaccines 

• Pharmacotherapy 

• Use therapies based on severity of COPD

COPD - Free CE Continuing Education online pharmacy, pharmacists

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