Drug Topics- August 11, 2008

54 DRUG TOPICS AUGUST 11, 2008 www.drugtopics.com CONTINUING EDUCATION Acute exacerbations of chronic bronchitis Patients with chronic bronchitis will have 1.5 to three occurrences of acute exacerbations of chronic bronchitis (AECB) annually. Chronic bronchitis is defined as the presence of productive cough on most days of the week for at least three months over two consecutive years. Other symptoms include shortness of breath, purulent sputum, and increased DT CAPSULE sputum tenacity. AECB is esPrior to choosing empiric sentially acute therapy for a CAP patient, worsening of antibiotic resistance within these symptoms, unstable the local community lung function, should be considered. and worsening airflow. AECB can be classified as mild (worsening in one baseline symptom), moderate (worsening of two baseline symptoms), and severe (worsening of ≥three baseline symptoms). AECB may be infectious in nature. Viral exacerbations are frequently associated with dyspnea, sore throat, and other cold-like symptoms. Bacterial exacerbations are usually characterized by neutrophilic inflammation, such as increased sputum production or purulence. Research has shown that inflammatory markers such as interleukin-6 and -8, tumor necrosis factor-alpha, neutrophil elastase, and serum fibrinogen increase with bacterial AECB. Chest X-rays are not commonly used to diagnose AECB unless patients present with atypical symptoms or pneumonia is suspected. The predominant viral pathogens involved in AECB include influenza and rhinoviruses. Other common respiratory viruses discussed previously have also been found to cause AECB. In contrast to acute bronchitis, bacteria play a larger role in AECB. S. pneumoniae, H. influenzae, and M. catarrhalis are the predominant pathogens found in AECB. Pseudomonas aeruginosa has been implicated in more severe cases of AECB. Less than 10% AECB are caused by atypical bacteria, with C. pneumoniae being the most predominant, followed by Mycoplasma pneumoniae and Legionella pneumoniae. Treatment of AECB focuses on three goals: resolving symptoms quickly, lengthening the time between exacerbations, and stopping further lung damage due to infection and inflammation. In order to resolve symptoms quickly, patients should be given oxygen to help shortness of breath. If the patient is already receiving bronchodilator therapy, increasing the dose or adding a short-acting bronchodilator will also help with shortness of breath. In severe cases, adding a systemic corticosteroid, such as prednisone, may help improve lung function by decreasing inflammation. The optimal dose and duration of steroid use is to be determined, but recent studies have shown lung function improves between three to five days of steroid therapy, so one may infer that steroid therapy should be given for at least five days. Increased hydration and chest physical therapy (e.g., oscillating positive expiratory pressure) to help thin and remove sputum may also benefit patients, although studies of effectiveness have been inconclusive. The use of antibiotics in AECB remains controversial. Most clinicians agree that antibiotics are necessary in moderate and severe cases of AECB and in those patients at high risk of relapse (e.g., AECB within past week, advanced age, chronic steroid use, severe lung damage, malnutrition). When considering treatment with antibiotics, the prescriber should consider the spectrum activity, resistance patterns of the area, tracheobronchial penetration, and cost. Increasing drug resistance by S. pneumoniae and poor penetration make penicillins and most cephalosporins poor choices for AECB. However, high-dose amoxillin/clavulanate (Augmentin, 875 twice daily or 500 mg three times daily) has shown efficacy in AECB. Studies have supported the use of fluoroquinolones and macrolides as the most effective therapies in AECB. Head-to-head studies of moxifloxacin 400 mg daily for five days or levofloxacin 500 mg for seven days versus azithromycin (Z-pack 500mg on the first day then 250mg daily for four days) showed equal efficacy. However, resistance to the macrolides by S. pneumoniae is increasing, and these drugs should be used judiciously. Doxycycline may be used if M. catarrhalis is the sole pathogen or an alternative if the patient cannot tolerate macrolides or fluoroquinolones. Depending on the antibiotic prescribed, duration of treatment should be five to 10 days, and the patient’s symptoms should return to baseline. If a patient is not improving within 24 to 36 hours after initiation of antibiotic treatment, reevaluation is necessary. Otitis media Otitis media (or inflammation of the middle ear) is a common infection in children. At least 80% of children will receive this diagnosis at least once by three years of age. In fact, age is one of the greatest risk factors for infection, with the age of six to 24 months showing an increased prevalence. Other risk factors that also contribute include but are not limited to increased exposure to other children that may occur as a result of daycare or other siblings, cigarette smoking in the household, pacifier use, seasonal exposures to pathogens, and even ethnic origin. Symptoms in children and infants include pulling on the ears (potentially indicating pain), irritability, ear discharge, and possible fever. These symptoms frequently follow a viral respiratory infection but may also appear in conjunction with the “cold” symptoms of nasal discharge, cough, or gastrointestinal upset as well. Symptoms of severe inner ear pain or a temperature greater than 39°C or 102.2°F may be classified as severe. Common pathogens include S. pneumoniae, H. influenzae, and M. catarrhalis, the same pathogens often seen in other upper respiratory tract infections. It is important to note that no bacterial pathogen is identified in up to 30% of patients. Thus the treatment decision for this infectious condition is frequently empiric and symptomatic in nature. http://www.drugtopics.com

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Drug Topics- August 11, 2008 Contents Latebreakers Letters DEA Proposes Rule To Allow Electronic Prescriptions for Controlled Substances Merger, Medicare Reform Could Mean Broader E-Prescribing Adoption New Combination Pill Approved for Type 2 Diabetes New Eczema Guildlines Promote Use of Emollients, Then Topical Corticosteroids Agencies Flush Original Strategies in Favor of Promoting Drug Take-Back Programs JP at Large: You Laughing at Me? Pharmacists Find Themselves at Mercy of Prior Authorization State Law Requiring PBM Transparency See Some Gains, Some Losses Global Counterfeiting Still Growing, Says U.S. Commerce Official FDA Saftey Page: Prophylthiouracil Still Confused with Purinethol (mercaptopurine) New Products Bring Lice Treatment to a Head NACDS Marketplace Showcases New Product that Fill Unmet Needs Update on Respiratory Tract Infections Execs Share War Stories About Adopting Technology in their Stores New Products Advertisters Index Classified Viewpoint: Medicare Part D Revisions sorely needed

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