COPD
Medications in COPD Management
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Medications in COPD Management
, COPD Preparations
See Also
COPD Management
Acute Exacerbation of Chronic Bronchitis
Antibiotic Use in COPD Exacerbation
COPD
Chronic Bronchitis
Emphysema
Alpha-1-Antitrypsin Deficiency
COPD Staging
COPD Exacerbation Prevention
COPD Action Plan
Preparations
Bronchodilator
s - Inhaled Beta-agonists
Efficacy
Spirometry
improved 15% and decreased rate of annual FEV1 decline with
Long-acting Beta Agonist
(LABA)
Significant symptom improvement also suggests benefit
Use with spacer always due to lack of lung excursion
Give prn unless jittery (precedes cardiotoxicity)
Safety
Low risk of precipitating major cardiovascular events in
COPD
without
Asthma
Salpeter (2004) Chest 125:2309-21 [PubMed]
Comorbid
Asthma
, however, is associated with adverse outcomes with
Long-acting Beta Agonist
(LABA)
LABA use in
Asthma
was associated with increased
Asthma
deaths, increased intubations and hospitalizations
McMahon (2011) Pediatrics 128(5): e1147-54 [PubMed]
Short-acting Beta Agonist
for rescue
Albuterol
2 puffs every 4-6 hours prn
In crisis, may be used up to 6-8 puffs q1-2 hours
Levalbuterol
(
Xopenex
hfa) 2 puffs every 4-6 hours
Pirbuterol
(
Maxair
Autohaler) 1-2 pufss every 4-6 hours prn
Long-acting Beta Agonist
for maintenance
Arformoterol
(
Brovana
) 15 mcg twice daily
Formoterol
(
Foradil
) once twice daily
Indacaterol
(
Arcapta
) once daily
Salmeterol
(
Serevent
Discus) once twice daily
Effective and safe (no increased vascular events)
Ferguson (2003) Chest 123:1817-24 [PubMed]
Preparations
Bronchodilator
s - Inhaled
Anticholinergic
s (e.g.
Ipratropium Bromide
)
Efficacy
Greater bronchodilation than Beta agonists in
COPD
Combined with beta agonist may offer additive effect
No tachyphylaxis
Decreases bronchoconstriction by inhibiting cGMP
Safety
Short-acting
Anticholinergic
s (e.g.
Ipratropium
) are associated with increased cardiovascular events
Avoid short acting
Anticholinergic
s (
Ipratropium
) in comorbid cardiovascular disease
Ogale (2010) Chest 137(1): 13-19 [PubMed]
Singh (2008) JAMA 300(12): 1439-50 [PubMed]
Preparations
Short-acting agents (see safety precautions above)
Ipratropium Bromide
(
Atrovent
) 2-3 puffs qid
In crisis may be used up to 6 to 8 puffs q3-4 hours
Ipratropium Bromide
500 ug vial nebulized qid
Long-acting agents
Aclidinium
(
Tudorza
) once twice daily
Tiotropium
(
Spiriva
) once daily
Short-Acting Combination agents
Duoneb (Nebulized
Ipratropium Bromide
and
Albuterol
)
Combivent
(
Ipratropium
with
Albuterol
)
Significant cost savings when combined
Benayoun (2001) Chest 119:85-92 [PubMed]
Long-Acting Combination Agents
Anoro Ellipta
(
Umeclidinium
and vilanterol)
Once daily preparation (2014 release in U.S.)
Long acting
Anticholinergic
(umeclidinum) and long acting beta agonist (vilanterol)
Stiolto
Respimat (
Tiotropium
and olodaterol)
Two inhalations once daily (2015 release in U.S.)
Long acting
Anticholinergic
(
Tiotropium
) and long acting beta agonist (olodaterol)
Preparations
Systemic Corticosteroid
s
Short course
Corticosteroid
s in severe exacerbation
Increases FEV1 and shortens hospital stay
Avoid use longer than 2 weeks
Protocol (total of 10 day course at full strength)
Solu-Medrol 1-2 mg/kg q6-12 hours IV for 3 days
IV
Corticosteroid
s are not more effective than oral
Corticosteroid
s
Prednisone
40 mg daily for 5 days
Equivalent to 10-14 day courses (see above)
Prolonged
Prednisone
tapers off over 2 weeks are not indicated in most cases
Long-term
Systemic Corticosteroid
s not often helpful
Long-term
Corticosteroid
use is rarely indicated
Beneficial effects seen in only 10-20%
COPD
patients
Test to see if
COPD
patient
Corticosteroid
responsive
Prednisone
40 mg PO for 10 days
Alternative:
Theophylline
challenge
Test PFTs before and after course
Attempt to slowly discontinue
Corticosteroid
s
Decrease
Corticosteroid
dose by 5 mg per week
Most patients tolerate taper without rebound
No change in
Spirometry
No change in symptoms (e.g.
Dyspnea
)
Stopping steroids often alleviates adverse effects
Anticipate resolution of prior weight gain
Risk of
Osteoporosis
with long-term steroid use
See
Corticosteroid Associated Osteoporosis
Dubois (2002) Chest 121:1456-63 [PubMed]
References
Rice (2000) Am J Respir Crit Care Med 162:174-8 [PubMed]
Preparations
Inhaled Corticosteroid
s
Fluticasone with
Salmeterol
(
Advair
Diskus)
Significant benefit compared with either agent alone
Resulted in symptom control and sustained for >1 year
No significant adverse effects seen in studies
Calverly (2003) Lancet 361:449-56 [PubMed]
Hanania (2003) Chest 124:834-43 [PubMed]
Possible impact on exacerbations and quality of life
May decrease exacerbations by one event per every 4 years
Consider in patients with FEV1 < 1.5 Liters (<50%)
Consider if frequent exacerbations
Consider trial for 6-18 weeks
Check PFTs before and after course
Corticosteroid
s are not uniformly effective in
COPD
Eosinophil Count
>300 cells/ul (>4% of total WBC) predicts steroid responsiveness
Eosinophil Count
only has predictive value if off inhaled and
Systemic Corticosteroid
s
COPD
may still respond to steroids despite low
Eosinophil Count
Pascoe (2019) Lancet Respir Med 7(9):745-56 [PubMed]
Pulmonary Function Test
s do not reflect full benefit
Decrease annual FEV1 decline (44 ml/year, similar to long acting
Bronchodilator
s)
Minimal impact on lung function
No impact on rate of lung function decline
Inhaled Corticosteroid
s do not reduce mortality
Inhaled Corticosteroid
s are not recommended as monotherapy in
COPD
Adverse effects may outweigh benefits
Agents are expensive (many are over $100 per month)
Mild effects:
Bruising
,
Dysphonia
,
Candidiasis
Serious effects
Osteoporosis
Cataract
s
Pneumonia
Number Needed to Harm (NNH): 50 in 18 months
Kew (2014) Cochrane Database Syst Rev 3:CD010115 [PubMed]
Consider tapering off high dose fluticasone or other
Inhaled Corticosteroid
in stable
COPD
patients
Taper over 12 weeks to prevent exacerbation and consider maintaining at low dose if symptoms increase
Avoid discontinuing
Inhaled Corticosteroid
s in oxygen dependent
COPD
or those on oral
Corticosteroid
s
Magnussen (2014) N Engl J Med 371:1285-94 [PubMed]
Preparations
Systemic
Bronchodilator
s
Leukotriene Receptor Antagonist
(e.g.
Accolate
)
Rarely used in
COPD
Some prior data showed efficacy when cobined with
Bronchodilator
Theophylline
10-15 mg/kg to drug level 10-12 ug/ml
Recent guidelines do not recommend in exacerbation (however still in GOLD guidelines as alternative agent)
Narrow therapeutic range (before reaching toxic levels)
Several serious
Drug Interaction
s (e.g.
Quinolone
s)
Review interactions at every medication change
Efficacy in stable
COPD
Weak
Bronchodilator
Weaker than Beta agonists (e.g.
Albuterol
)
Weaker than
Anticholinergic
s (e.g.
Atrovent
)
Improves respiratory
Muscle Strength
and endurance
Improves mucociliary clearance
Increases central respiratory drive
May lead to symptomatic improvement
Associated with reduced hospitalization rate
Appears synergistic with long-acting
Bronchodilator
ZuWallack (2001) Chest 119:1661 [PubMed]
Preparations
Home Oxygen
Indications
Stable clinical Status
No end-organ dysfunction:
PaO2
< 55 mmHg or O2 < 88%
End Organ changes:
PaO2
< 59 mmHg or O2 < 90%
Cor Pulmonale
or
Right Heart Failure
P-pulmonale on EKG
Polycythemia present (
Hematocrit
>55%)
Documentation
Arterial Blood Gas
(ABG) OR
O2 Sat
measured at rest for 30 min on room air OR
O2 Sat
after 6 minute ambulation
Document with and without oxygen
Benefits
Home Oxygen use only beneficial if >15-18 hours/day
Decreases exertional and nocturnal
Dyspnea
Increases life span in
COPD
by 6-7 years (if resting
PaO2
<55 mmHg)
Goal to keep
Oxygen Saturation
88-92% (or
PaO2
>60 mmHg)
Adjuncts
Consider Continuous Positive Airway Pressure (
CPAP
)
Resources
Global Initiative for
Chronic Obstructive Lung Disease
http://www.goldcopd.com
References
(1995) Am J Respir Crit Care Med 152(5 pt 2):S77-121 [PubMed]
Celli (1998) Postgrad Med 103(4):159-76 [PubMed]
Cooper (1997) Ann Thorac Surg 63:312-9 [PubMed]
Donohue (2002) Chest 122:47-55 [PubMed]
Fein (2000) Curr Opin Pulm Med 6:122-6 [PubMed]
Gentry (2017) Am Fam Physician 95(7): 433-41 [PubMed]
Hunter (2001) Am Fam Physician 64(4):603-12 [PubMed]
Lee (2013) Am Fam Physician 88(10): 655-63 [PubMed]
Obrien (1998) Postgrad Med 103(4):179-202 [PubMed]
Qaseem (2011) Ann Intern Med 155(3): 179-91 [PubMed]
Runo (2001) West J Med 175:197-201 [PubMed]
Sayiner (2001) Chest 119:726-30 [PubMed]
Voelkel (2000) Chest 117(5 suppl 2):S376-9 [PubMed]
Weg (1998) Postgrad Med 103(4):143-55 [PubMed]
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