COPD is a challenging disease that ultimately leads to a progressive reduction in lung function. Our mainstays of therapy are the bronchodilators like long-acting anticholinergic and long-acting beta-agonists. Roflumilast (podcast) is a unique medication for COPD in that it is taken orally. I want to discuss roflumilast clinical pearls and where this medication might be utilized in helping patients with COPD.
Let’s start with the indication of roflumilast. The best evidence for using roflumilast is in the setting of frequent COPD exacerbations. Keeping the patient out of the hospital is a good thing and for those who are already maxed out on inhalers and still having exacerbations, roflumilast could be a potential option for them.
Roflumilast Clinical Pearls – Adverse Effects
There are some potentially troublesome adverse effects from roflumilast. Nausea, vomiting, and diarrhea have all been reported with diarrhea being the most prominent adverse effect to look out for. Keep an eye out for patients requiring loperamide or other antidiarrheals as this may be an indicator that the patient is not tolerating roflumilast.
Coupled with the GI issues that can be caused by roflumilast is the risk of weight loss. This can be very problematic in patients who may be elderly and frail already. Monitoring weight and appetite are important to think about and if you see medications added to stimulate appetite (such as mirtazapine, dronabinol, or megestrol), roflumilast should be at the forefront of your mind as a potential contributing factor to weight loss.
Patients with a significant history of psychiatric illness should be monitored closely when using roflumilast. While rare, there have been reports of severe psychiatric changes such as suicide, and attempted suicide. If I see a patient on numerous antidepressants, anxiolytics, antipsychotics, or other psychiatric medications, I would definitely take the time to review the risk versus potential benefit of using roflumilast.
Roflumilast Drug Interactions
Drug interactions are a potential problem when using roflumilast. This is something that we definitely don’t have to worry about as much when using inhaled agents like LAMA, LABA, or ICS therapy. Roflumilast is significantly broken down by CYP3A4. Inhibitors will increase drug concentrations and inducers will lower drug concentrations. As I discuss in this article on seven common types of drug interactions, CYP3A4 is one of the most common enzymes that is affected by drugs. So naturally, roflumilast can be affected by a large number of medications.
What other roflumilast clinical pearls do you think about when you see an order for this medication?
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