What is the best medication for chronic obstructive pulmonary disease (COPD) with emphysema?

From the Guidelines

The most effective treatment for chronic obstructive pulmonary disease (COPD) with emphysema is a combination of a long-acting muscarinic antagonist (LAMA) and a long-acting β2-agonist (LABA), with the option to add an inhaled corticosteroid (ICS) for patients with a high risk of exacerbations or concomitant asthma, as recommended by the 2023 Canadian Thoracic Society guideline 1.

Treatment Options

• For patients with mild symptoms and low risk of exacerbations, a LAMA or LABA monotherapy may be sufficient 1.
• For patients with moderate to severe symptoms or high risk of exacerbations, a LAMA/LABA combination therapy is preferred, with the option to add an ICS for patients with concomitant asthma or high risk of exacerbations 1.
• Inhaled corticosteroids should only be used in combination with a LAMA and LABA, and not as monotherapy, due to the increased risk of adverse events such as pneumonia 1.

Medication Options

• LAMA options include tiotropium (Spiriva, 18 mcg once daily) 1.
• LABA options include salmeterol (Serevent, 50 mcg twice daily) 1.
• ICS options include fluticasone (100-500 mcg twice daily) 1.

Additional Therapies

• Phosphodiesterase-4 inhibitors like roflumilast (500 mcg once daily) may be considered for patients with severe symptoms or frequent exacerbations, but are not recommended as first-line therapy due to limited evidence and potential adverse events 1.
• Oxygen therapy may be necessary for patients with severe hypoxemia, and pulmonary rehabilitation and vaccination against respiratory infections should be considered for all patients with COPD 1.

Key Considerations

• Treatment should be individualized based on symptom burden, risk of exacerbations, and mortality risk, and should be accompanied by regular follow-up with a healthcare provider to adjust medications as needed 1.
• The 2023 Canadian Thoracic Society guideline provides a comprehensive approach to the pharmacotherapy of COPD, and should be consulted for detailed recommendations and guidance 1.

From the FDA Drug Label

TUDORZA PRESSAIR is a prescription medicine to treat chronic obstructive pulmonary disease (COPD). COPD is a long-term (chronic) lung disease that includes chronic bronchitis, emphysema, or both. Tiotropium bromide inhalation powder is a prescription medicine used each day (a maintenance medicine) to control symptoms of chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema. Fluticasone Furoate/Vilanterol ELLIPTA is a prescription medicine used long term (chronic) to treat people with: Chronic Obstructive Pulmonary Disease (COPD): o Fluticasone Furoate/Vilanterol ELLIPTA is a prescription medicine used to treat COPD COPD is a chronic lung disease that includes chronic bronchitis, emphysema, or both.

The best medication for chronic obstructive pulmonary disease (COPD) with emphysema is not explicitly stated in the provided drug labels. However, based on the information provided, the following medications are used to treat COPD, including emphysema:

• Aclidinium (TUDORZA PRESSAIR): an anticholinergic medicine that helps the muscles around the airways in the lungs stay relaxed to prevent symptoms such as wheezing, cough, chest tightness, and shortness of breath.
• Tiotropium bromide: a maintenance medicine that controls symptoms of COPD, including chronic bronchitis and emphysema, by relaxing the airways and keeping them open.
• Fluticasone Furoate/Vilanterol ELLIPTA: a prescription medicine used to treat COPD, which includes chronic bronchitis, emphysema, or both, by combining an inhaled corticosteroid (ICS) medicine and a long-acting beta2-adrenergic agonist (LABA) medicine.

It is essential to consult a healthcare provider to determine the most suitable medication for a specific patient's condition, as the best treatment option may vary depending on individual factors, such as medical history, severity of symptoms, and other health conditions. 2, 3, 4

From the Research

Medication Options for COPD with Emphysema

• Long-acting inhaled bronchodilator medications, including long-acting muscarinic antagonists (LAMA) and long-acting β2-agonists (LABA), are recommended as initial maintenance therapy for many patients with COPD 5.
• Combinations of long-acting bronchodilator agents (LAMA/LABA) and inhaled corticosteroids combined with LABA (ICS/LABA) are also used as initial or follow-up therapy in patients with more severe symptoms or at risk of COPD exacerbations 5.

Efficacy of LAMA/LABA Combinations

• LAMA/LABA treatment leads to greater improvements in lung function and symptoms than LAMA monotherapy or ICS/LABA treatment 5.
• The LABA/LAMA combination is the highest ranked treatment group to reduce COPD exacerbations, followed by LAMA in both high-risk and low-risk populations 6.
• There is evidence that the LABA/LAMA combination decreases moderate to severe exacerbations compared to LABA/ICS combination, LAMA, and LABA in the high-risk population 6.

Safety of LAMA/LABA Combinations

• The incidence of adverse events is similar with LAMA/LABA and LAMA alone 5.
• There is a lower risk of pneumonia with LAMA/LABA compared with ICS/LABA 5, 6.
• ICS-containing inhalers are associated with an increased risk of pneumonia 6.

Specific Medications

• Tiotropium bromide, a long-acting muscarinic antagonist (LAMA), is safe and efficacious as a long-term, once-daily LAMA for the maintenance treatment of COPD and for reducing COPD exacerbations 7.
• Once-daily LABA/LAMA combinations, such as IND/GLY, UMEC/VI, and TIO/OLO, are associated with a clinically significant improvement in lung function and health-related quality of life in patients with mild-to-moderate COPD 8.