What medications should I order for a patient with COPD (Chronic Obstructive Pulmonary Disease) exacerbation, both as needed (prn) and scheduled?

From the Guidelines

For a patient with COPD exacerbation, I recommend a combination of scheduled and as-needed medications, prioritizing short-acting bronchodilators, systemic corticosteroids, and long-acting bronchodilators to reduce morbidity, mortality, and improve quality of life. The core treatment should include a short-acting bronchodilator such as albuterol (2-4 puffs every 4-6 hours as needed) and ipratropium bromide (2 puffs every 6 hours as needed) or a combination product like Combivent Respimat (1 inhalation four times daily) 1. Systemic corticosteroids are essential, typically prednisone 40mg daily for 5 days, as they improve lung function, oxygenation, and shorten recovery time and hospitalization duration 1. For scheduled medications, continue or initiate a long-acting bronchodilator regimen with a long-acting beta-agonist (LABA) such as formoterol or salmeterol, and a long-acting muscarinic antagonist (LAMA) like tiotropium 18mcg daily.

Some key points to consider:

• Antibiotics are indicated if there are signs of infection, with azithromycin 500mg on day 1 followed by 250mg daily for 4 days being a common choice 1.
• Supplemental oxygen should be provided to maintain oxygen saturation ≥88% 1.
• An inhaled corticosteroid may be added for patients with frequent exacerbations, typically as part of a combination inhaler 1.
• Maintenance combination inhaled corticosteroid/long-acting b-agonist therapy is recommended for patients with stable moderate to very severe COPD to prevent acute exacerbations 1.

These medications work together to reduce airway inflammation, relieve bronchospasm, and improve airflow, addressing the underlying pathophysiology of COPD exacerbations which involves increased inflammation and airway resistance. It is crucial to follow the most recent and highest quality guidelines, such as those from the American College of Chest Physicians and Canadian Thoracic Society 1, and the American Academy of Family Physicians 1, to ensure the best possible outcomes for patients with COPD exacerbations.

From the FDA Drug Label

The use of ipratropium bromide inhalation solution as a single agent for the relief of bronchospasm in acute COPD exacerbation has not been adequately studied. Combination of ipratropium bromide and beta agonists has not been shown to be more effective than either drug alone in reversing the bronchospasm associated with acute COPD exacerbation. In patients with chronic obstructive pulmonary disease (COPD), clinical studies have shown that theophylline decreases dyspnea, air trapping, the work of breathing, and improves contractility of diaphragmatic muscles with little or no improvement in pulmonary function measurements.

For a patient with COPD exacerbation, ipratropium bromide may be considered as part of the treatment regimen, but its use as a single agent has not been adequately studied 2. Theophylline may also be considered, as it has been shown to decrease dyspnea and improve diaphragmatic muscle contractility in COPD patients 3. However, beta agonists may be preferred as initial therapy due to their faster onset of action.

• Prn medications may include ipratropium bromide and beta agonists.
• Scheduled medications may include theophylline, with careful attention to dose reduction and frequent monitoring of serum concentrations.

From the Research

Medications for COPD Exacerbation

The following medications can be ordered for a patient with COPD exacerbation:

• Oxygen (in hypoxemic patients) 4
• Inhaled beta2 agonists (e.g. albuterol) 4, 5, 6, 7
• Inhaled anticholinergics (e.g. ipratropium bromide) 4, 5, 6, 8
• Antibiotics (directed at common pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) 4, 5, 8
• Systemic corticosteroids 4, 5, 8
• Methylxanthine therapy (may be considered in patients who do not respond to other bronchodilators) 4, 5

PRN Medications

The following medications can be ordered as needed (prn) for a patient with COPD exacerbation:

• Inhaled beta2 agonists (e.g. albuterol) for acute bronchospasm 7
• Inhaled anticholinergics (e.g. ipratropium bromide) for acute bronchospasm 8
• Oxygen (in hypoxemic patients) for acute hypoxemia 4

Scheduled Medications

The following medications can be ordered on a scheduled basis for a patient with COPD exacerbation:

• Inhaled beta2 agonists (e.g. albuterol) every 4-6 hours 7
• Inhaled anticholinergics (e.g. ipratropium bromide) every 4-6 hours 8
• Systemic corticosteroids (e.g. methylprednisolone) every 12 hours 8
• Antibiotics (e.g. doxycycline, trimethoprim-sulfamethoxazole, amoxicillin-clavulanate potassium) every 12 hours 4, 8