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

From the Guidelines

Inhalers for Chronic Obstructive Pulmonary Disease (COPD) should include LABD maintenance therapy, with single inhaler dual therapy LABD recommended for patients with moderate to severe dyspnea and/or poor health status, and single-inhaler triple therapy for those with persistent symptoms despite dual therapy, as per the 2023 Canadian Thoracic Society guideline 1.

Overview of COPD Inhalers

Inhalers for COPD management are crucial for controlling symptoms, preventing exacerbations, and improving quality of life. The primary classes of inhalers include:

• Long-acting beta-agonists (LABAs)
• Long-acting muscarinic antagonists (LAMAs)
• Inhaled corticosteroids (ICS)

Recommendations Based on Recent Guidelines

The 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD recommends LABD maintenance therapy in all symptomatic patients confirmed by spirometry 1. For patients with moderate to severe dyspnea and/or poor health status, single inhaler dual therapy LABD is suggested, with a step up to single-inhaler triple therapy in those with persistent symptoms despite treatment with single inhaler dual therapy.

Key Points for Inhaler Use in COPD

• LABD maintenance therapy is recommended for all symptomatic patients with COPD confirmed by spirometry.
• Single inhaler dual therapy LABD is recommended for patients with moderate to severe dyspnea and/or poor health status.
• Single-inhaler triple therapy should be considered for patients with persistent moderate to severe dyspnea and/or poor health status despite treatment with single inhaler dual therapy.
• Proper inhaler technique and the use of spacer devices can improve medication effectiveness.

Considerations for Treatment

Treatment should be stepped up progressively based on symptom control and exacerbation frequency, with the goal of alleviating symptoms, preventing exacerbations, and reducing mortality, as suggested by the 2023 guideline 1.

From the FDA Drug Label

The efficacy of fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg and fluticasone propionate and salmeterol inhalation powder 500 mcg/50 mcg in the treatment of subjects with COPD was evaluated in 6 randomized, double-blind, parallel-group clinical trials in adult subjects aged 40 years and older The recommended dosage for patients with COPD is 1 inhalation of Wixela Inhub® 250/50 twice daily, approximately 12 hours apart.

The inhalers for Chronic Obstructive Pulmonary Disease (COPD) are:

• Fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg
• Fluticasone propionate and salmeterol inhalation powder 500 mcg/50 mcg
• Wixela Inhub® 250/50 Key points:
• The dosage is 1 inhalation twice daily, approximately 12 hours apart.
• If shortness of breath occurs in the period between doses, an inhaled, short-acting beta2-agonist should be taken for immediate relief 2, 2.

From the Research

Types of Inhalers for COPD

• Long-acting inhaled bronchodilators, such as tiotropium, salmeterol, and formoterol, are commonly used as initial maintenance therapy for patients with stable, symptomatic COPD 3.
• Long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs) are the cornerstone of treatment for symptomatic patients with COPD, either as initial/first-line treatment or for second-line/treatment escalation in patients who experience persistent symptoms or exacerbations on monotherapy 4.
• Dual bronchodilator therapy (LABA/LAMA) is recommended for patients with more severe symptoms, regardless of exacerbation history 4.
• The combination of LAMAs and LABAs is thought to leverage different pathways to induce bronchodilation using submaximal drug doses, increasing the benefits and minimizing receptor-specific side effects 5.

Examples of Inhalers for COPD

• Tiotropium: a long-acting anticholinergic inhaled bronchodilator 3, 6.
• Salmeterol: a long-acting β2-agonist inhaled bronchodilator 3, 6.
• Formoterol: a long-acting β2-agonist inhaled bronchodilator 3, 6.
• Umeclidinium/vilanterol: a combination of LAMA/LABA approved for use in stable COPD 5.
• Indacaterol/glycopyrronium and aclidinium/formoterol: combinations of LAMA/LABA approved in Europe and numerous locations outside the USA 5.

Treatment Guidelines for COPD

• The Global Initiative for Chronic Obstructive Lung Disease guidelines recommend the use of at least one of the two classes of long-acting inhaled bronchodilators as initial maintenance therapy for symptomatic COPD 3, 4.
• The American Thoracic Society treatment guidelines strongly recommend LABA/LAMA combination therapy over LAMA or LABA monotherapy in patients with COPD and dyspnea or exercise intolerance 4.
• Treatment guidelines recommend the addition of inhaled corticosteroids (ICS) to LABA/LAMA only in patients with a history of frequent/severe exacerbations and high blood eosinophil counts, or in those with concomitant asthma 7.