What are the treatment options for Chronic Obstructive Pulmonary Disease (COPD)?

Treatment Options for Chronic Obstructive Pulmonary Disease (COPD)

Bronchodilators are the cornerstone of COPD treatment, with therapy escalating based on disease severity from short-acting agents for mild disease to combination therapies including long-acting bronchodilators and inhaled corticosteroids for more severe disease. 1

Disease Severity Classification

Treatment should be tailored according to COPD severity:

• Mild COPD: FEV1 >80% predicted
• Moderate COPD: FEV1 50-80% predicted
• Severe COPD: FEV1 30-50% predicted
• Very Severe COPD: FEV1 <30% predicted 1

Pharmacological Treatment Algorithm

Mild COPD

• Patients with no symptoms: No drug treatment required
• Patients with symptoms: Short-acting bronchodilators as needed
  • Short-acting β2-agonist (e.g., albuterol) OR
  • Short-acting anticholinergic (e.g., ipratropium) 2
  • If these drugs are ineffective, they should be discontinued 2

Moderate COPD

• First-line: Long-acting muscarinic antagonist (LAMA) such as tiotropium 1, 3
• Alternative: Long-acting β2-agonist (LABA) such as salmeterol 4
• Most patients can be controlled on a single drug, though some may require combination treatment 2
• Oral bronchodilators are not usually required at this stage 2

Severe COPD

• Combination therapy: LAMA + LABA for patients with persistent symptoms 1
• Add inhaled corticosteroid (ICS) for:
  • Patients with blood eosinophil count ≥300 cells/μL
  • History of asthma
  • Frequent exacerbations 1
• Consider theophyllines but monitor closely for side effects 2
• Salmeterol/fluticasone combination (Wixela Inhub 250/50) twice daily is indicated for:
  • Maintenance treatment of airflow obstruction
  • Reducing exacerbations in patients with a history of exacerbations 4

Very Severe COPD

• Triple therapy: LABA/LAMA/ICS for patients with continued symptoms or exacerbations 1
• Consider nebulized bronchodilators after proper assessment by a respiratory physician 2
• Roflumilast for patients with FEV1 <50% predicted and chronic bronchitis 1

Delivery Devices

• Metered dose inhalers (MDIs) are the most cost-effective but require proper technique 2
• Dry powder inhalers (DPIs) may be easier to use for some patients 2
• Nebulizers should be reserved for:
  • Patients with severe disease who benefit from high-dose bronchodilator treatment
  • Those who cannot use MDIs or DPIs properly
  • Only after assessment by a respiratory physician 2

Non-Pharmacological Interventions

Smoking Cessation

• Most effective strategy for slowing disease progression and reducing mortality 1
• Requires counseling and pharmacotherapy (NRT, bupropion, varenicline) 1

Pulmonary Rehabilitation

• Improves exercise performance and reduces breathlessness in moderate/severe disease 1
• Reduces exacerbations and hospitalizations 1

Oxygen Therapy

• Long-term oxygen therapy (LTOT) prolongs life in hypoxemic patients 1, 5
• Should be prescribed if PaO₂ <7.3 kPa or SaO₂ <90% 1
• Administer for at least 15 hours/day to improve survival 1

Exercise

• Encourage continued activity within limitations of airways obstruction 2
• Breathlessness on exertion may be distressing but is not dangerous 2

Management of Exacerbations

• Increase dose/frequency of short-acting bronchodilators 1
• Antibiotics indicated if two or more of:
  • Increased breathlessness
  • Increased sputum volume
  • Development of purulent sputum 1
• Oral corticosteroids (30 mg daily for one week) in select cases 1

Surgical Options

• Consider surgery for:
  • Recurrent pneumothoraces
  • Isolated bullous disease
  • Lung volume reduction in selected patients 1
• Lung transplantation for end-stage disease in patients <65 years with:
  • Very poor exercise tolerance
  • FEV1 <25% predicted
  • PaO₂ <7.5 kPa and PaCO₂ >6.5 kPa 1

Common Pitfalls and Caveats

• Beta-blockers (including eyedrop formulations) should be avoided in COPD patients 2
• Inhaler technique must be demonstrated and regularly checked 2
• No evidence supports prophylactic antibiotics, mucolytics, antihistamines, or pulmonary vasodilators 2
• Nebulizers should not be prescribed without proper assessment, as they are expensive and may have important side effects 2
• Nutritional support is important as malnutrition is common in severe COPD and may contribute to mortality 2
• Depression and anxiety should be screened for and treated as they contribute to symptom intensity 1

By following this structured approach to COPD management based on disease severity, clinicians can optimize treatment to improve symptoms, reduce exacerbations, and potentially slow disease progression.