What are the treatment options for emphysema?

Treatment Options for Emphysema

Long-acting bronchodilators (LABAs and LAMAs) should be the first-line pharmacological treatment for emphysema, with combination therapy recommended for patients with persistent symptoms or exacerbations. 1

Pharmacological Treatment Options

First-Line Therapy

• Long-acting bronchodilators:
  • Long-acting muscarinic antagonists (LAMAs) such as tiotropium 18 mcg once daily 2
  • Long-acting beta-agonists (LABAs) such as formoterol or salmeterol
  • For patients with persistent symptoms, LABA/LAMA combinations are superior to monotherapy 1, 3

Second-Line and Add-on Therapies

• For patients with frequent exacerbations:

  • Consider adding inhaled corticosteroids (ICS) to LABA therapy 1
  • For patients who continue to have exacerbations on LABA/LAMA therapy, consider escalation to LABA/LAMA/ICS 1

• For patients with continued exacerbations despite triple therapy:

  • Consider adding roflumilast (for patients with FEV1 <50% predicted and chronic bronchitis) 1
  • Consider adding a macrolide (in former smokers) 1

Special Considerations

• Alpha-1 antitrypsin deficiency: For patients with severe hereditary alpha-1 antitrypsin deficiency and established emphysema, augmentation therapy should be considered 1

  • Intravenous administration of purified human AAT concentrate at 60 mg/kg body weight has been shown to increase lung levels of AAT 1

• Oxygen therapy:

  • Supplemental oxygen reduces mortality rates in patients with resting hypoxemia (SaO2 <90%) 1
  • Consider for patients who desaturate during exercise 1

Non-Pharmacological Treatment Options

Pulmonary Rehabilitation

• Strongly recommended for patients with high symptom burden (groups B, C, and D) 1
• Benefits include:
  • Improved endurance
  • Reduced dyspnea
  • Reduced hospitalizations
  • Improved quality of life 1

Smoking Cessation

• Most important intervention for patients who continue to smoke 1
• Options include:
  • Behavioral support
  • Nicotine replacement therapy
  • Pharmacotherapy (varenicline, bupropion)

Advanced Interventions

• Lung volume reduction for selected patients with severe emphysema
• Lung transplantation for appropriate candidates with end-stage disease

Treatment Algorithm Based on Symptom Severity

1. Mild symptoms, low exacerbation risk:

   • Short-acting bronchodilator as needed
   • Consider long-acting bronchodilator if symptoms persist

2. More severe symptoms, low exacerbation risk:

   • Long-acting bronchodilator (LAMA preferred)
   • Consider LABA/LAMA combination if symptoms persist

3. High exacerbation risk:

   • Start with LABA/LAMA combination
   • Consider adding ICS if blood eosinophil count is elevated or if patient has features of asthma-COPD overlap

4. Continued exacerbations despite optimal therapy:

   • Escalate to triple therapy (LABA/LAMA/ICS)
   • Consider adding roflumilast or macrolide

Common Pitfalls and Caveats

• Overuse of inhaled corticosteroids: ICS should not be used as monotherapy and increase risk of pneumonia 1
• Undertreatment of symptoms: Many patients remain symptomatic on monotherapy and should be escalated to combination therapy
• Neglecting non-pharmacological interventions: Pulmonary rehabilitation and smoking cessation are critical components of treatment
• Inadequate inhaler technique: Proper inhaler technique should be regularly assessed and reinforced
• Missing alpha-1 antitrypsin deficiency: Consider screening, especially in younger patients or those with family history 1, 4

By following this comprehensive approach to emphysema management, focusing on both pharmacological and non-pharmacological interventions tailored to symptom severity and exacerbation risk, patients can experience improved lung function, reduced symptoms, and better quality of life.