MC is a 62 year old male patient that presents to your ambulatory care clinic. He appears well but asks to speak to the pharmacist. He has new complaints of urinary retention that have not resolved over the past month and was considering making an appointment to be seen by his primary care physician since it has not resolved. 

PMH:

Hypertension

Hyperlipidemia

COPD

GERD

Medications:

Amlodipine 10 mg PO QD

Zocor 20 mg PO daily

Zetia 10 mg PO daily

Pepcid 20 mg PO daily prn

Prevacid 30 mg PO daily

Breo Ellipta 100/25mcg 1 inh daily

Spiriva Respimat 2.5mcg 2 inh daily

Proair HFA 1-2 inh q4-6h prn

Which medication is most likely contributing to the patient's complaint?

A. Prevacid

B. Breo Ellipta

C. Spiriva

D. Proair 

Chronic Obstructive Pulmonary Disease (COPD) is an incurable progressive lung disease characterized by chronic respiratory symptoms and airflow limitation due to airway and/or alveolar abnormalities. COPD is one of the leading causes of death in the entire world. It is primarily caused by environmental factors such as cigarette smoke and air pollution. Common clinical manifestations include dyspnea, cough, and sputum production. Common pharmacological treatment includes bronchodilators such as short and long acting beta agonists and muscarinic antagonists and inhaled corticosteroids. To date, treatment with these medication classes primarily improves quality of life and may decrease the risk of hospitalizations from COPD (corticosteroids), but have minimal impact on mortality. 

It is vital for pharmacists to be familiar with both generic and brand names, especially with various inhaled options used for COPD and Asthma. Exam questions can be asked in either the generic or brand name. Many options contain two or even three medications so confusion can arise often leading to potential misfills. 

Answer A is incorrect. Prevacid is a proton pump inhibitor (PPI) and is not known to cause any of these symptoms. Chronic PPI use can be associated with a number of electrolyte disorders, such as hypocalcemia, hypomagnesemia, and vitamin B-12 deficiency. 

Answer B is incorrect. Breo Ellipta is composed of a long acting beta agonist (vilanterol) and an inhaled corticosteroid (fluticasone). These classes are not associated with the above symptoms. Patients should rinse their mouth out after using this product to decrease the risk of fungal thrush infection. 

Answer C is correct. Spiriva belongs to the class of long acting muscarinic antagonists(LAMAs). LAMAs are known to cause anticholinergic effects. Potential anticholinergic effects include dry mouth, dry eyes, urinary retention and constipation. These effects are much less common that traditional systemic agents with anticholinergic pharmacologic activity (e.g. diphenhydramine) as they have much less systemic exposure due to their inhaled dosage form. 

Answer D is incorrect. Proair is a short acting beta agonist that is commonly used as a “rescue inhaler”. Common side effects include tachycardia and/or CNS stimulation, especially with high doses/frequencies. It is not however commonly associated with anticholinergic side effects. 

Brand/Generics covered: Amlodipine (Norvasc), Simvastatin (Zocor), Ezetimibe (Zocor), Famotidine (Pepcid), Lansoprazole (Prevacid), Tiotropium (Spiriva), Fluticasone /Vilanterol (Breo Ellipta), Albuterol (Proair)

NAPLEX Competencies covered:

Area 1 – Obtain, Interpret, or Assess Data, Medical, or Patient Information

1.4 - From medical records: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background

Area 2 – Identify Drug Characteristics

2.1 - Pharmacology, mechanism of action, or therapeutic class

2.2 - Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied

Area 3 – Develop or Manage Treatment Plans

3.5 - Drug route of administration, dosage forms, or delivery systems

3.7 - Adverse drug effects, toxicology, or overdose

3.8 - Drug interactions

3.9 - Therapeutic monitoring parameters, monitoring techniques, monitoring tools, or monitoring frequency