What is the best approach to manage a chronic cough in a patient with Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

Optimizing COPD maintenance therapy with bronchodilators and addressing comorbidities is crucial for managing chronic cough in COPD patients. The best approach begins with using bronchodilators such as long-acting beta-agonists (LABAs) like salmeterol or formoterol and long-acting muscarinic antagonists (LAMAs) like tiotropium, which help reduce airway inflammation and bronchoconstriction 1. For patients with frequent exacerbations and persistent cough, adding inhaled corticosteroids (ICS) like fluticasone or budesonide may be beneficial, typically as part of a combination inhaler.

Key Considerations

• Mucolytics such as N-acetylcysteine (600-1200 mg daily) can help thin mucus and improve clearance.
• Addressing comorbidities is crucial, particularly gastroesophageal reflux disease (GERD), which may require proton pump inhibitors like omeprazole 20-40 mg daily, and post-nasal drip, which might need treatment with antihistamines or nasal corticosteroids.
• Pulmonary rehabilitation improves cough clearance through breathing techniques and physical conditioning.
• Smoking cessation is essential as continued smoking perpetuates airway inflammation and cough.
• Adequate hydration (2-3 liters daily) helps maintain optimal mucus viscosity, while avoiding known irritants like air pollution and strong odors can prevent cough triggers.

Evidence-Based Recommendations

The 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD provides evidence-based recommendations for the optimal approach to the pharmacological treatment of individuals with COPD to alleviate symptoms, improve health status, and prevent exacerbations 1. This guideline emphasizes the importance of a comprehensive approach to COPD management, including confirming a diagnosis of COPD with spirometry, evaluating symptom burden, health status, and risk of exacerbations over time, and implementing pharmacological and nonpharmacological treatments.

Prioritizing Morbidity, Mortality, and Quality of Life

In managing chronic cough in COPD patients, it is essential to prioritize morbidity, mortality, and quality of life as outcomes. The most recent and highest-quality study, the 2023 Canadian Thoracic Society guideline, provides a comprehensive approach to COPD management, including pharmacological and nonpharmacological treatments 1. By following this guideline and addressing comorbidities, healthcare providers can improve symptoms, health status, and prevent exacerbations, ultimately reducing morbidity, mortality, and improving quality of life for COPD patients.

From the FDA Drug Label

The use of Wixela Inhub is NOT indicated for the relief of acute bronchospasm. Wixela Inhub 250/50 is indicated for the twice-daily maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema. If shortness of breath occurs in the period between doses, an inhaled, short-acting beta2-agonist should be taken for immediate relief

The best approach to manage a chronic cough in a patient with Chronic Obstructive Pulmonary Disease (COPD) is to use a medication that helps control symptoms of COPD.

• Maintenance treatment: Wixela Inhub 250/50 is indicated for the twice-daily maintenance treatment of airflow obstruction in patients with COPD.
• Relief of acute bronchospasm: If shortness of breath occurs, an inhaled, short-acting beta2-agonist should be taken for immediate relief. However, Wixela Inhub is not indicated for the relief of acute bronchospasm. No information is provided about the management of chronic cough. 2 Another option for maintenance treatment of COPD is STIOLTO RESPIMAT, a combination of tiotropium bromide and olodaterol, which is indicated for long-term, once-daily maintenance treatment of patients with COPD. 3

From the Research

Management of Chronic Cough in COPD

• The management of chronic cough in patients with Chronic Obstructive Pulmonary Disease (COPD) involves a combination of pharmacotherapies and lifestyle modifications 4, 5, 6.
• Long-acting bronchodilators (LABAs) and long-acting muscarinic antagonists (LAMAs) are commonly used to control symptoms and reduce exacerbations 4, 6.
• Inhaled corticosteroids (ICS) may be added to LABAs or LAMAs for patients with a history of exacerbations and elevated eosinophils 5, 7.
• The combination of roflumilast plus LAMA has been shown to have a high probability of being the best first-line treatment for reducing exacerbations 4.

Pharmacotherapy Options

• LABAs, such as salmeterol, and LAMAs, such as tiotropium, are effective in reducing exacerbations and improving lung function 4, 6.
• ICS, such as fluticasone propionate and budesonide, may be used in combination with LABAs or LAMAs to reduce exacerbations, but their use should be limited to patients with a clear indication and careful assessment of the individual risk-benefit profile 5, 7.
• Roflumilast, a phosphodiesterase-4 inhibitor, has been shown to reduce exacerbations when added to LAMAs 4.

Personalized Approach

• A personalized approach to COPD management is advocated, taking into account the individual patient's risk-benefit profile and disease severity 5, 8.
• Patients with frequent exacerbations should be identified and treated with a combination of pharmacotherapies, including LABAs, LAMAs, and ICS, as needed 8.
• Regular monitoring and adjustment of treatment are necessary to optimize disease management and reduce exacerbations 6, 8.