What are the medications in a Chronic Obstructive Pulmonary Disease (COPD) action plan?

From the Guidelines

A COPD action plan should include a combination of bronchodilators, such as short-acting beta-agonists (SABAs) and short-acting muscarinic antagonists (SAMAs), as well as long-acting bronchodilators, including long-acting beta-agonists (LABAs) and long-acting muscarinic antagonists (LAMAs), to manage symptoms and prevent exacerbations. The cornerstone medications include bronchodilators such as SABAs like albuterol (2 puffs every 4-6 hours as needed) and SAMAs like ipratropium (2 puffs 4 times daily) 1. For maintenance therapy, long-acting bronchodilators are essential, including LABAs such as salmeterol (50 mcg twice daily) or formoterol (12 mcg twice daily), and LAMAs like tiotropium (18 mcg once daily) or umeclidinium (62.5 mcg once daily) 1.

Key Medications

• Short-acting beta-agonists (SABAs) like albuterol
• Short-acting muscarinic antagonists (SAMAs) like ipratropium
• Long-acting beta-agonists (LABAs) like salmeterol or formoterol
• Long-acting muscarinic antagonists (LAMAs) like tiotropium or umeclidinium

For patients with frequent exacerbations or more severe disease, inhaled corticosteroids (ICS) may be added, often in combination with LABAs, such as fluticasone/salmeterol (250/50 mcg twice daily) or budesonide/formoterol (160/4.5 mcg twice daily) 1. During exacerbations, oral corticosteroids like prednisone (40 mg daily for 5 days) and antibiotics such as azithromycin (500 mg on day 1, then 250 mg daily for 4 days) may be prescribed. These medications work by reducing airway inflammation and relaxing airway muscles to improve airflow, helping patients breathe more easily and reducing the frequency and severity of COPD flare-ups.

Additional Considerations

• Combination treatment with LABA and LAMA increases FEV1 and reduces symptoms compared with monotherapy 1
• Combination treatment with LABA and LAMA reduces exacerbations compared with monotherapy or ICS/LABA 1
• Tiotropium improves the effectiveness of pulmonary rehabilitation in increasing exercise performance 1

From the FDA Drug Label

1. 1 Sympathomimetics, Methylxanthines, Steroids In clinical studies, concurrent administration of aclidinium bromide and other drugs commonly used in the treatment of COPD including sympathomimetics (short-acting beta2 agonists), methylxanthines, and oral and inhaled steroids showed no increases in adverse drug reactions.

The medications in a Chronic Obstructive Pulmonary Disease (COPD) action plan may include:

• Sympathomimetics (short-acting beta2 agonists)
• Methylxanthines
• Oral and inhaled steroids
• Anticholinergics (such as aclidinium bromide) 2

From the Research

Medications in a COPD Action Plan

The following medications are commonly used in a Chronic Obstructive Pulmonary Disease (COPD) action plan:

• Bronchodilators, including:
  • Inhaled short-acting beta2-agonists (e.g. salbutamol) for relief of acute bronchospasm 3
  • Inhaled long-acting beta2-agonists (e.g. salmeterol, formoterol) for maintenance therapy 3, 4
  • Inhaled short-acting anticholinergic agents (e.g. ipratropium) 3
  • Inhaled long-acting anticholinergic agents (e.g. tiotropium, glycopyrronium, aclidinium) 3, 5, 4
• Inhaled corticosteroids (e.g. fluticasone, beclomethasone, budesonide) for patients with severe COPD and frequent exacerbations 3, 5, 4
• Combination therapies, including:
  • LABA/LAMA (long-acting beta2-agonist/long-acting muscarinic antagonist) combinations (e.g. salmeterol/fluticasone and tiotropium) 5, 6, 7
  • LABA/ICS (long-acting beta2-agonist/inhaled corticosteroid) combinations (e.g. fluticasone/salmeterol) 5, 7

Rationale for Medication Use

The use of these medications is supported by evidence from various studies, including:

• A study published in 2007, which found that bronchodilators are the mainstay of COPD therapy, and that combination therapy with a bronchodilator and a corticosteroid provides greater improvements in lung function and symptoms than individual agents alone 3
• A systematic review and network meta-analysis published in 2018, which found that LABA/LAMA combinations are the most effective treatment for reducing COPD exacerbations, and that LAMA-containing inhalers may have an advantage over those without a LAMA for preventing COPD exacerbations 5
• A randomized controlled trial published in 2008, which found that combination therapy with salmeterol/fluticasone and tiotropium leads to better control of symptoms and improved lung function, with no greater risk of side effects, compared to salmeterol/fluticasone or tiotropium alone 6
• A study published in 2012, which found that the addition of fluticasone/salmeterol to tiotropium significantly improves lung function and reduces rescue albuterol use, without increasing the risk of adverse events 7
• A review published in 2016, which found that inhaled beta2-agonists, antimuscarinics, and corticosteroids have modest, mainly symptomatic efficacy in COPD, and that treatment should be adapted to symptoms and the frequency of exacerbations 4