What are the recommended treatments and inhalers for Chronic Obstructive Pulmonary Disease (COPD)?

COPD Treatment and Inhalers

For patients with COPD, a stepwise approach using bronchodilators as the cornerstone of therapy is recommended, with long-acting bronchodilators (LABAs and LAMAs) as maintenance therapy and short-acting bronchodilators for rescue, while inhaled corticosteroids should be reserved for specific phenotypes with frequent exacerbations and elevated eosinophil counts. 1

Initial Assessment and Classification

• COPD severity should be assessed using:
  • Symptom burden (using mMRC or CAT scores)
  • Lung function impairment (FEV1)
  • History of exacerbations
  • Presence of comorbidities

Pharmacological Treatment

Bronchodilators - First Line Therapy

1. Short-acting bronchodilators

   • Short-acting β2-agonists (SABA): salbutamol (albuterol), terbutaline
   • Short-acting anticholinergics: ipratropium bromide
   • Used as needed for immediate symptom relief 2
   • Delivered via MDI with spacer or nebulizer

2. Long-acting bronchodilators

   • Long-acting β2-agonists (LABAs): salmeterol, formoterol
   • Long-acting muscarinic antagonists (LAMAs): tiotropium, glycopyrronium
   • Recommended for regular maintenance therapy in moderate to severe COPD 1
   • Dosing: typically once or twice daily depending on the specific medication 3

Treatment Algorithm Based on Severity

Mild COPD

• Short-acting bronchodilator as needed 2, 1

Moderate COPD

• Regular use of single long-acting bronchodilator (LABA or LAMA) 1
• SABA for rescue therapy
• Consider pulmonary rehabilitation 1

Moderate to Severe COPD

• LAMA/LABA combination therapy (e.g., tiotropium/olodaterol or glycopyrronium/formoterol) 1
• Provides superior bronchodilation compared to monotherapy 4

Severe COPD with Frequent Exacerbations

• Triple therapy: LAMA/LABA/ICS for patients with:
  • Blood eosinophil counts ≥300 cells/μL 1
  • History of frequent exacerbations
  • Number needed to treat (NNT) of 4 to prevent one moderate-severe exacerbation per year 1

Corticosteroids

• Inhaled corticosteroids (ICS)

  • Not recommended as monotherapy in COPD 1
  • Should always be combined with long-acting bronchodilators 1
  • Indicated primarily for patients with:
    • Frequent exacerbations
    • Blood eosinophil counts ≥300 cells/μL
    • Mixed asthma/COPD phenotype
  • Increased risk of pneumonia (NNH of 33) 1, 5

• Systemic corticosteroids

  • Reserved for acute exacerbations
  • Short course (10-14 days) of oral prednisone 30-40 mg daily 2
  • Not for long-term maintenance therapy

Other Pharmacological Options

• PDE4 inhibitors (e.g., roflumilast)

  • Not recommended as first-line therapy 1
  • Consider for patients with chronic bronchitis phenotype and frequent exacerbations

• Antibiotics

  • For acute exacerbations with change in sputum characteristics 2
  • Options include amoxicillin/clavulanate or respiratory fluoroquinolones 2
  • Consider macrolide maintenance therapy (e.g., azithromycin) in appropriate patients with normal QT interval and frequent exacerbations 1

Non-Pharmacological Interventions

1. Smoking cessation

   • Essential at all stages of disease 2
   • Most effective intervention to slow disease progression

2. Pulmonary rehabilitation

   • Improves dyspnea, exercise tolerance, and quality of life 1
   • Should be incorporated alongside pharmacological therapy

3. Oxygen therapy

   • Long-term oxygen therapy (LTOT) for patients with resting hypoxemia (PaO2 <7.3 kPa) 2
   • Reduces mortality in hypoxemic patients 2

4. Ventilatory support

   • Consider non-invasive positive pressure ventilation (NPPV) for acute respiratory failure 2

Inhaler Selection and Technique

• Device selection should consider:

  • Patient's ability to generate adequate inspiratory flow
  • Hand-breath coordination
  • Cognitive function

• Most patients can effectively use:

  • Metered-dose inhalers (MDIs) with spacers
  • Dry powder inhalers (DPIs)
  • Soft mist inhalers

• Proper inhaler technique should be demonstrated and checked regularly 2

Management of Exacerbations

1. Increased bronchodilator therapy

   • Increased frequency of short-acting bronchodilators 2
   • Consider nebulized therapy for severe exacerbations

2. Systemic corticosteroids

   • Prednisone 30-40 mg daily for 10-14 days 2
   • Helps prevent subsequent exacerbations within 30 days 1

3. Antibiotics

   • When there is a change in sputum purulence/volume 2
   • Choice based on local resistance patterns

Monitoring and Follow-up

• Assess response to therapy by evaluating:

  • Improvement in dyspnea
  • Exercise tolerance
  • Quality of life
  • Frequency of exacerbations

• Consider treatment escalation if symptoms persist despite current therapy

• Monitor for adverse effects, particularly pneumonia with ICS-containing regimens

Common Pitfalls to Avoid

1. Using ICS as monotherapy in COPD (never appropriate) 1
2. Overuse of ICS in patients without clear indications
3. Inadequate bronchodilator therapy before escalating to combination treatments
4. Neglecting non-pharmacological interventions like smoking cessation and pulmonary rehabilitation
5. Not checking inhaler technique regularly, leading to suboptimal drug delivery
6. Failing to adjust oxygen flow rates appropriately in patients with CO2 retention

By following this evidence-based approach to COPD management, clinicians can optimize symptom control, reduce exacerbations, and potentially slow disease progression while minimizing adverse effects.