What inhalers should be prescribed for a new Chronic Obstructive Pulmonary Disease (COPD) patient at discharge?

From the Guidelines

For a new COPD patient at discharge, I recommend starting with a long-acting bronchodilator, typically either a long-acting muscarinic antagonist (LAMA) such as tiotropium (Spiriva) 18 mcg once daily or a long-acting beta-agonist (LABA) such as salmeterol (Serevent) 50 mcg twice daily, as supported by the American College of Chest Physicians and Canadian Thoracic Society guideline 1.

Key Considerations

• For patients with more severe symptoms or frequent exacerbations, a combination of both LAMA and LABA may be appropriate, such as umeclidinium/vilanterol (Anoro Ellipta) 62.5/25 mcg once daily.
• Additionally, all patients should have a rescue inhaler like albuterol (ProAir, Ventolin) 90 mcg, 1-2 puffs every 4-6 hours as needed for breakthrough symptoms.
• For patients with a history of exacerbations and elevated eosinophil counts, adding an inhaled corticosteroid may be beneficial, often as part of a combination inhaler like fluticasone/vilanterol (Breo Ellipta) 100/25 mcg once daily, as recommended by the Global Initiative for Chronic Obstructive Lung Disease 1.

Treatment Goals

• The goal of treatment is to minimize the negative impact of the current exacerbation and to prevent subsequent events, as stated in the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1.
• Treatment should be tailored to the individual patient's symptom severity, exacerbation history, and comorbidities, taking into account the recommendations from the European Respiratory Society task force 1 and the American College of Chest Physicians and Canadian Thoracic Society guideline 1.

Proper Inhaler Technique

• Proper inhaler technique should be demonstrated and verified before discharge, and patients should understand the difference between maintenance and rescue medications, as emphasized in the example answer.
• Patients should be educated on the proper use of their inhalers, including the correct technique for administering the medication and the importance of regular use, as recommended by the American College of Chest Physicians and Canadian Thoracic Society guideline 1.

From the FDA Drug Label

Always have a beta2-agonist inhaler medicine (rescue inhaler) with you to treat sudden symptoms of COPD If you do not have a rescue inhaler, contact your healthcare provider to have one prescribed for you.

For a new Chronic Obstructive Pulmonary Disease (COPD) patient at discharge, the following inhalers should be prescribed:

• A long-acting inhaler such as tiotropium (e.g. STIOLTO RESPIMAT) for long-term control of COPD symptoms
• A short-acting beta2-agonist inhaler (rescue inhaler) for immediate relief of sudden COPD symptoms Note: The specific type of long-acting inhaler and short-acting beta2-agonist inhaler may vary depending on the patient's individual needs and medical history, as determined by their healthcare provider 2.

From the Research

Inhalers for COPD Patients

When discharging a new Chronic Obstructive Pulmonary Disease (COPD) patient, the choice of inhalers is crucial for managing their condition. The following options are considered:

• Long-acting beta-agonists (LABAs): Salmeterol and formoterol are examples of LABAs, which have a 12-hour duration of action and are used with a twice-daily dosing regimen for long-term COPD treatment 3.
• Inhaled corticosteroids (ICS): Combination with ICS, such as fluticasone/salmeterol, budesonide/formoterol, and beclomethasone/formoterol, may provide additional benefits over monocomponent therapy, although the extent of this benefit can vary 3, 4.
• Ultra-LABAs: Newer ultra-LABAs, including olodaterol, vilanterol, milveterol, carmoterol, and abediterol, are in development and may offer improved efficacy and convenience 3.
• Long-acting muscarinic receptor antagonists (LAMAs): Tiotropium is an example of a LAMA, which can be used in combination with LABAs or ICS to improve lung function and reduce exacerbations 5.
• Combination therapy: Combination of LABAs and LAMAs, or LABAs and ICS, may provide improved outcomes compared to monotherapy 4, 6, 5.

Key Considerations

When selecting inhalers for COPD patients, consider the following:

• Patient subphenotyping: Identifying patients with frequent exacerbations, sputum eosinophilia, or mixed asthma/COPD phenotype may help determine the most effective treatment approach 3.
• Risk of pneumonia: Treatment with ICS is associated with an increased risk of pneumonia, which should be carefully considered when assessing the risk/benefit ratio of ICS/LABA combinations 3.
• Lung function and symptoms: Combination therapy with LABAs and ICS, or LABAs and LAMAs, may improve lung function and reduce symptoms compared to monotherapy 6, 5.