Feb 4, 2015

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

Ever heard a pug breathe? It is the funniest thing and always makes me smile. I was watching a show on TV that had a pug club sitting silently in a room. The mics just picked up the noises of a dozen or so pugs snort and wheeze and pant and just generally make hilarious sounds. Doriss sister has a pug, Buster. Buster has been a riot at family gatherings over the years. Hes broken into our dogs big bin of food, drank the yellow, licorice flavored Pernot liqueur Doriss dad preferred and was even used as a sled dog once. Granted Buster and our cavalier Mellie were only dragging around two year old Emily, but everyone seemed to have good time. But because of their short snouts and pushed in faces, pugs always seem to have breathing issues.

One of the common causes of breathing issues in older people is COPD. COPD or chronic obstructive pulmonary disease is a lung disease that is usually caused by smoking. It gets worse over time and although we can make someone with COPD's breathing a little easier with medication, we can't completely reverse the symptoms. As well as breathing problems, people with COPD can have nutrition issues and frequent infections. The most common symptoms are being short of breath and not being able to do the activities that you like to do.

In 2004, COPD was the fourth leading cause of death in Canada. That is up from the fifth leading cause of death in 1999. The number of deaths of women from COPD is rising faster than the number of deaths of men. It is expected in the next couple of years more women than men will die every year from COPD. Although it is probably under reported, it is estimated that over 700,000 Canadians have COPD. Smoking is the main cause of COPD. There are lots of complicated things going on inside the lungs during COPD. However, the main thing going wrong is the person with COPD can`t expel all the air in their lungs. This trapped air in the lungs makes it harder for the person with COPD to breathe.

We only have one treatment for COPD that will make the patient live longer. That is quitting smoking. It really, really is never too late to quit.

When I started practicing pharmacy, we usually treated COPD patients with fast acting salbutamol and ipratroprium inhalers. They helped patients breathing, but a patient had to use them several times per day. Then several years ago tiotroprium or spiriva came out. It was a little inconvenient because you had to load a capsule into the inhaler each time, but patients loved it. It was a once a day treatment and people felt great on it. They felt so great, that lots of people were willing to pay $80 a month for tiotroprium eventhough at first Manitoba Health didn`t cover it.

I`m hoping a new inhaler for COPD might be the next tiotroprium. It is a combination inhaler called ultibro. Apparently that is short for ultimate bronchodilator. It contains indacaterol and glycopyrronium. Indacaterol is in a class called a long acting beta agonist. We will shorten that to LABA. Glycopyrronium is called a long acting muscarinic antagonist. We will shorten that to LAMA. That means we call ultibro a LABA/LAMA combination product.

All these silly acronyms aside, this is what it means to people with COPD. Tiotroprium is a LAMA and people love it to treat their COPD. One shot lasts all day. We have used LABA's with and without steroids to treat asthma for years and they seem to work quite well. We have tried using LABA's with steroids in COPD. They worked well in some cases, but there are problems. Use of steroids in COPD may increase the chances of pneumonia and people with COPD are already at risk of pneumonia. There is also the suggestion that inhaled steroids may decrease bone mass and people with COPD are often older anyway. The inhaled steroid osteoporosis link is controversial though. The exciting thing is recent studies are showing LABA/LAMA combinations are improving breathing more than a LAMAs alone or than LABAs with a steroid. These are early days and there might be more contradictory studies coming, but LABA/LAMA combo's like ultibro seem to be the latest and greatest thing to treat COPD.

The ultibro inhaler device is similar to the tiotroprium device. You have to load a capsule and pierce it, so it is not the most user friendly thing. But people got good at the tiortroprium device, so with some pharmacist training, I'm sure they will get the hang of the ultibro.

COPD doesnt get better over time. Even oxygen therapy doesnt make you live longer with COPD. Only smoking cessation can decrease COPD mortality. But early diagnosis, proper exercise and the proper inhaler can help you live better with COPD. Having a breathing problem doesnt mean you cant have fun. Just ask Buster or any other pug. Whether hanging around at someones feet for any possible crumb they might drop while cooking, or proving small dogs can have a deep manly bark to scare off intruders, pugs breathe funny but they also seize every moment of every day.

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

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COPD guidelines -

Ultibro monograph -


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