What is the recommended discharge medication regimen for a patient with a chronic obstructive pulmonary disease (COPD) exacerbation?

Recommended Discharge Medication Regimen for COPD Exacerbation

The recommended discharge medication regimen for a patient with COPD exacerbation should include bronchodilators (short-acting beta-agonist and/or anticholinergic), oral corticosteroids to complete a 7-14 day course, antibiotics if started during hospitalization, and consideration of maintenance therapy with long-acting bronchodilators. 1

Bronchodilator Therapy

• Short-acting beta-agonists (SABA) via metered-dose inhaler (MDI) with spacer should be prescribed as the primary rescue medication, with dosing of 2 puffs every 2-4 hours as needed 1
• Consider adding ipratropium bromide MDI for patients with more severe symptoms or those who had poor response to beta-agonist alone during hospitalization 1
• MDI with spacer is as effective as nebulized therapy once the patient is stabilized and facilitates earlier discharge from hospital 1
• Ensure proper MDI technique is taught and demonstrated by the patient before discharge 1
• For maintenance therapy, consider adding a long-acting bronchodilator such as tiotropium 18 mcg once daily or salmeterol/fluticasone combination 2, 3

Corticosteroid Therapy

• Oral prednisone 30 mg daily should be prescribed to complete a 7-14 day course if the patient received systemic corticosteroids during treatment 4, 1
• Oral corticosteroids should not be continued long-term after an exacerbation 4
• For patients with frequent exacerbations, consider adding inhaled corticosteroids by MDI as part of maintenance therapy 1

Antibiotic Therapy

• Ensure the patient completes the full 5-7 day course of antibiotics if started during treatment for purulent sputum or increased sputum volume 1
• Antibiotics should be prescribed if the patient has two or more of: increased breathlessness, increased sputum volume, or development of purulent sputum 4
• Common antibiotics such as amoxicillin, tetracycline, or amoxicillin/clavulanate are usually sufficient unless there was poor response 1

Maintenance Therapy Considerations

• For patients with moderate to severe COPD and history of exacerbations, consider combination therapy with inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) such as fluticasone/salmeterol 250/50 mcg twice daily 2
• Tiotropium 18 mcg once daily is an effective alternative maintenance therapy 3
• Some evidence suggests that combining ICS/LABA with tiotropium may provide additional benefits in symptomatic patients with severe COPD 5, 6

Oxygen Therapy

• If the patient required oxygen during hospitalization, assess the need for continued oxygen therapy at discharge 4
• Target oxygen saturation should be 90-93% 4
• Consider home oxygen evaluation if the patient remains hypoxic 4

Follow-up Considerations

• Schedule follow-up within 30 days of discharge to reduce risk of readmission 1
• The follow-up visit should include review of medication adherence, inhaler technique, and assessment for prevention of future exacerbations 4
• Provide advice on smoking cessation, lifestyle modifications, activity levels, and weight management 4

Important Pitfalls to Avoid

• Ensure transition from nebulizer to MDI occurs at least 24 hours prior to discharge to confirm stability on the discharge regimen 1
• Do not continue oral corticosteroids long-term without specific indications 4
• Avoid prescribing multiple long-acting beta-agonists simultaneously, as this increases risk of adverse effects 2
• Ensure patients understand the difference between maintenance and rescue medications to prevent overuse or underuse 1
• Pneumonia risk may be increased with ICS/LABA combinations compared to long-acting anticholinergics alone 7