2) This program is supported by an unrestricted educational grant from Insmed. Statement of accreditation & faculty disclosures at https://t.co/0EkFYk4TZx.
— pulmmed_ce (@Pulmmed_CE) August 21, 2023
FOLLOW US for the most current, expert-authored #MedEd! #FOAMed #pulmtwitter @MedTweetorials
4) She is on a thiazide diuretic for hypertension, a statin for hyperlipidemia, & an inhaled corticosteroid/#LABA for her asthma. She has no known drug allergies.
— pulmmed_ce (@Pulmmed_CE) August 21, 2023
6) Her vital signs are stable; she weighs 65kg. Her physical exam is notable for bilateral rhonchi in the mid-lung fields. pic.twitter.com/eLNYGeAUic
— pulmmed_ce (@Pulmmed_CE) August 21, 2023
8) Her pulmonary function testing #PFT shows some mild obstructive airways dysfunction. pic.twitter.com/NvtEiQidSv
— pulmmed_ce (@Pulmmed_CE) August 21, 2023
9b) The correct answer is B, start airway clearance. Let's keep moving.
— pulmmed_ce (@Pulmmed_CE) August 21, 2023
11) When #bronchiectasis is present, it becomes difficult for the patient to expectorate mucus, which becomes stagnant in the airways. This can lead to recurrent #inflammation and chronic #infection, one of them being non-tuberculous #mycobacteria (#NTM).
— pulmmed_ce (@Pulmmed_CE) August 21, 2023
13) Airway clearance is a mainstay of management in #bronchiectasis & #MAC, to help break the vicious vortex of inflammation and infection that develops. It can help reduce symptoms, improve quality of life #QoL, and possibly prevent further inflammation and lung destruction. pic.twitter.com/AP1s8bEUmy
— pulmmed_ce (@Pulmmed_CE) August 21, 2023
14b) There are some great websites that provide airway clearance teaching as well, including the bronchiectasis toolbox (https://t.co/YNwNKybWSH). If additional airway clearance is needed, high-frequency chest wall therapy can also be considered. pic.twitter.com/Uu5l1Espkn
— pulmmed_ce (@Pulmmed_CE) August 21, 2023
15) Identification of potential etiologies of #bronchiectasis should also be pursued. If a potential etiology is identified, it should be treated appropriately to try and prevent further bronchiectasis. pic.twitter.com/7FxEQ29oTi
— pulmmed_ce (@Pulmmed_CE) August 21, 2023
17) We often also send screening for #rheumatologic conditions, inflammatory markers, and an alpha-one #antitrypsin level as additional workup. pic.twitter.com/YcD0ZnSlNg
— pulmmed_ce (@Pulmmed_CE) August 21, 2023
18b) For cystic fibrosis, we often screen with a #sweatchloride test. If positive, we can consider a more comprehensive genetic sequencing test to assess for #CF mutations.
— pulmmed_ce (@Pulmmed_CE) August 21, 2023
20) Our pt meets criteria for dx of #MAC, based on the 2020 ATS/IDSA/ESCMID/IDSA #NTM guidelines. She has sx of MAC w/cough & sputum, rad findings w/bronchiectasis & bronchiolitis, + micro findings (2 of 3 #AFB sputum cultures + for MAC, w/exclusion of other likely etiologies).
— pulmmed_ce (@Pulmmed_CE) August 21, 2023
22a) Welcome back! You have rejoined @basavarajashwin, leading us through a clinical case that illustrates "Advanced Strategies for Timely Diagnosis & Guideline-Driven Individualized Treatment Plans for Patients with #NTM_LD. You are well on your way to 0.75hr 🆓 CE/#CME!
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
23a) On to managing such a pt:
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
Her #reflux should also be controlled, as reflux, aspiration and swallowing abnormalities can potentially contribute to worsening #bronchiectasis and MAC.
23c) If patients truly do not have #asthma, we can consider stopping her inhaled corticosteroid and switching to an alternative therapy, as inhaled steroids may contribute to worsening underlying chronic infectious process.
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
24) Back to our patient . . .
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
🫁 Despite airway clearance, her symptoms persisted.
🫁 She also now has a 5-pound weight loss, with worsening radiographic findings.
🫁 The sensitivities for her cultured #MAC are 👇 pic.twitter.com/Uw8KUSTtQZ
26) Not only do we look at whether a patient is sensitive or resistant to #macrolides and #amikacin, but we also look at the #MIC cut points for sensitivity. The MIC cut points for these antibiotics are 👇 pic.twitter.com/ucMuB5Y63z
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
28a) It's A, and in fact our pt was started on azithromycin, rifampin & ethambutol 3x/wk, which is recommended tx per the 2020 #NTM guidelines for mild-moderate nodular bronchiectatic #MAC 🫁 disease.
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
29a) For pts w/more severe nodular #bronchiectasis or cavitary disease, daily therapy should be considered, w/the option of adding IV #aminoglycoside therapy for the first 2-3 months of therapy.
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
30a) Despite 6mo tx for our pt, she remained symptomatic. Her #AFB cultures remained + for #MAC.
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
What med approved by @US_FDA for refractory #MAC can be considered for addition to our pt’s regimen?
A) Inhaled liposomal amikacin
B) Bedaquiline
C) Clofazamine
D) Fluoroquinolone
31) Approval was based on the #CONVERT study, which evaluated patients with refractory #MAC, who continued GBT alone vs patients who continued GBT + inhaled liposomal amikacin #ALIS.
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
See 🔓 https://t.co/Zp5MLcHI9X. pic.twitter.com/WQD2OYwPYg
33) There are also more recent data to suggest that in patients on GBT+ALIS, 63% of patients who culture converted to negative, remained negative on therapy, compared to 30% in the GBT alone arm (therapy was sustainable)
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
See 🔓 https://t.co/76DKbuR0Nk.
35) Thus, given that our patient was still symptomatic and culture positive after 6 months of GBT therapy, inhaled liposomal amikacin #ALIS was added to her regimen of azithromycin, ethambutol and rifampin.
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
36b) #CBC, #LFTs, and metabolic panels are also monitored every 1-3 months on antibiotic therapy to monitor for side effects. Frequency of blood work depends on the regimen, age, comorbidities, concurrent drugs, overlapping toxicities and resources.
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
36d) It’s important to educate patients on potential side effects, so they know what to expect. Nighttime dosing of antibiotic may help with nausea and other GI side effects. If side effects do occur, it is important to manage them quickly.
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
38) Here are some resources to learn more about #NTM lung disease:
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
🫁 https://t.co/yGoUvKcRS5
🫁 https://t.co/4R2OPh0k2Y
🫁 https://t.co/gAi9z2Vi14
39) And that's it! You just earned 0.75hr 🆓 CE/#CME! Claim your certificate at https://t.co/bOsby0QjKA. .@Pulmmed_CE & @basavarajashwin thank you for joining & encourage you to FOLLOW US for more 🫁 #MedEd!
— pulmmed_ce (@Pulmmed_CE) August 22, 2023
👏to @shannonturvey @CHESTPrez @laura22rush @KessnerJp @PulmAdvisor