What are the treatment options for Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

From the Guidelines

Treatment for Chronic Obstructive Pulmonary Disease (COPD) exacerbation should begin with short-acting bronchodilators, such as albuterol and ipratropium, and systemic corticosteroids, like prednisone, to reduce inflammation and speed recovery. According to the most recent and highest quality study 1, the goal of treatment is to minimize the negative impact of the current exacerbation and prevent subsequent events.

Key Treatment Components

• Short-acting inhaled β2-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation 1.
• Systemic corticosteroids improve lung function and oxygenation, and shorten recovery time and hospitalization duration, with a recommended duration of therapy not exceeding 5-7 days 1.
• Antibiotics are indicated if there are signs of bacterial infection and can shorten recovery time and reduce the risk of early relapse, treatment failure, and hospitalization duration, with a recommended duration of 5-7 days 1.
• Non-invasive ventilation (NIV) should be the first mode of ventilation used in patients with COPD and acute respiratory failure who have no absolute contraindication, as it improves gas exchange, reduces the work of breathing, and decreases hospitalization duration and mortality 1.

Additional Considerations

• Methylxanthines are not recommended due to their side effect profiles 1.
• After an exacerbation, appropriate measures for exacerbation prevention should be initiated, including review of proper inhaler technique, ensuring appropriate maintenance therapy, and addressing smoking cessation if applicable.
• Supplemental oxygen should be provided to maintain oxygen saturation at 88-92% to prevent hypoxemia and its complications.
• For severe exacerbations, hospitalization may be necessary for more intensive treatment, including possible non-invasive ventilation, and patients should follow up within 1-2 weeks after discharge to review their condition and adjust treatment as needed.

From the FDA Drug Label

The effect of roflumilast 500 mcg once daily on COPD exacerbations was evaluated in five 1-year trials (Trials 3,4,5,6 and 9).

Two of the trials (Trials 3 and 4) conducted initially enrolled a population of patients with severe COPD (FEV 1 ≤50% of predicted) inclusive of those with chronic bronchitis and/or emphysema who had a history of smoking of at least 10 pack years

The rate of moderate or severe COPD exacerbations was a co-primary endpoint in both trials

Trial 5 randomized a total of 1525 patients (765 on roflumilast) and Trial 6 randomized a total of 1571 patients (772 on roflumilast)

In both trials, roflumilast 500 mcg once daily demonstrated a significant reduction in the rate of moderate or severe exacerbations compared to placebo (Table 2).

Treatment options for Chronic Obstructive Pulmonary Disease (COPD) exacerbation include:

• Roflumilast 500 mcg once daily, which has been shown to reduce the rate of moderate or severe exacerbations in patients with severe COPD associated with chronic bronchitis and a history of exacerbations.
• Add-on therapy to a fixed-dose combination (FDC) product containing an inhaled corticosteroid and long-acting beta agonist (ICS/LABA) 2.
• Long-acting muscarinic antagonists, which were allowed in some trials 2.
• Inhaled corticosteroids, which were allowed as concomitant medications in some trials 2.
• Short-acting beta agonists, which were allowed as rescue therapy in some trials 2.

From the Research

Treatment Options for COPD Exacerbation

The treatment options for Chronic Obstructive Pulmonary Disease (COPD) exacerbation include:

• Increasing the dosage of inhaled short-acting bronchodilators, such as ipratropium and albuterol, to relieve dyspnea 3
• Using oral corticosteroids, which are likely beneficial, especially for patients with purulent sputum 3
• Administering antibiotics to reduce the risk of treatment failure and mortality in moderately or severely ill patients, with the choice of antibiotic guided by local resistance patterns and the patient's recent history of antibiotic use 3, 4
• Providing regular doses of short-acting bronchodilators, continuous supplemental oxygen, antibiotics, and systemic corticosteroids for hospitalized patients 3
• Using noninvasive positive pressure ventilation or invasive mechanical ventilation in patients with worsening acidosis or hypoxemia 3, 4

Pharmacological Strategies

Pharmacological strategies to reduce exacerbation risk in COPD include:

• Maximizing bronchodilation as an initial strategy to reduce exacerbation risk, using a long-acting muscarinic antagonist (LAMA)/ long-acting β2-agonist (LABA) combination 5
• Adding inhaled corticosteroids (ICS) to a LABA/LAMA combination in exacerbating patients who have an asthma-COPD overlap syndrome or high blood eosinophil counts 5
• Using a phosphodiesterase (PDE)-4 inhibitor (roflumilast) or high-dose mucolytic agents in exacerbators with chronic bronchitis 5
• Adding mucolytic agents or a macrolide antibiotic (e.g. azithromycin) in patients who experience frequent bacterial exacerbations and/or bronchiectasis 5

Comprehensive Management Plan

A comprehensive management plan for COPD exacerbation should include:

• Pulmonary rehabilitation 5, 6
• Self-management education 6
• Preventive strategies to reduce exacerbations, such as smoking cessation, immunization against influenza and S. pneumonia, and chronic maintenance inhaled pharmacotherapy 6