What is the treatment for recurrent Chronic Obstructive Pulmonary Disease (COPD) exacerbations in an elderly male?

From the Guidelines

For an 82-year-old man with recurrent COPD exacerbations, the most effective treatment strategy should prioritize a combination of a long-acting muscarinic antagonist (LAMA) and a long-acting beta-agonist (LABA), with the consideration of adding an inhaled corticosteroid (ICS) for patients with a history of exacerbations and moderate to very severe COPD, as evidenced by the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 report 1.

Acute Management

The immediate treatment of a COPD exacerbation includes a short course of oral corticosteroids, such as prednisone 40mg daily for 5 days, and a broad-spectrum antibiotic like azithromycin if an infection is suspected, as suggested by the prevention of acute exacerbations of COPD guideline 1. Supplemental oxygen should be provided to maintain oxygen saturation at 88-92%. Intensification of bronchodilator therapy with short-acting beta-agonists like albuterol and anticholinergics like ipratropium is also recommended.

Prevention of Future Exacerbations

For maintenance therapy, a LAMA such as tiotropium 18mcg once daily, combined with a LABA, is a cornerstone of treatment. The addition of an ICS, like fluticasone/salmeterol 250/50mcg twice daily, may be considered for patients with a history of exacerbations and moderate to very severe COPD, as it has been shown to improve lung function, health status, and reduce exacerbations 1. Roflumilast 500mcg daily may be considered for patients with chronic bronchitis and severe COPD, as it reduces moderate and severe exacerbations treated with systemic corticosteroids 1.

Additional Considerations

Pulmonary rehabilitation is essential to improve exercise capacity and quality of life. Vaccination against influenza annually and pneumococcal pneumonia is crucial. In elderly patients, medication side effects must be monitored closely, and inhaler technique should be regularly assessed to ensure proper medication delivery. The goal is to reduce inflammation, improve airflow, treat any underlying infection, and implement strategies to prevent future exacerbations while considering age-related factors like comorbidities and potential drug interactions.

• Key points for management:
  • Use of LAMA and LABA as the foundation of maintenance therapy.
  • Consideration of ICS for patients with a history of exacerbations and moderate to very severe COPD.
  • Roflumilast for patients with chronic bronchitis and severe COPD.
  • Pulmonary rehabilitation and vaccination against influenza and pneumococcal pneumonia.
  • Close monitoring of medication side effects and inhaler technique in elderly patients.

From the FDA Drug Label

The 2 exacerbation trials with fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg were identical trials designed to evaluate the effect of fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg and salmeterol 50 mcg, each given twice daily, on exacerbations of COPD over a 12-month period In both trials, treatment with fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg resulted in a significantly lower annual rate of moderate/severe COPD exacerbations compared with salmeterol (30.5% reduction [95% CI: 17.0,41.8], P< 0.001) in the first trial and (30.4% reduction [95% CI: 16.9,41.7], P< 0. 001) in the second trial. Exacerbations of COPD were defined as a complex of lower respiratory events/symptoms (increase or new onset) related to the underlying COPD, with duration of three days or more, requiring a prescription of antibiotics and/or systemic steroids and/or hospitalization In a pooled analysis of the first two trials, tiotropium 5 mcg significantly reduced the number of COPD exacerbations compared to placebo with a rate ratio of 0.78 (95% CI 0.67,0.92).

For an 82-year-old man with recurrent COPD exacerbation, the treatment options include:

• Fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg: This combination has been shown to reduce the annual rate of moderate/severe COPD exacerbations compared to salmeterol alone 2.
• Tiotropium 5 mcg: This medication has been shown to reduce the number of COPD exacerbations compared to placebo 3. It is essential to consider the patient's age, medical history, and current symptoms when selecting a treatment option. A conservative clinical decision would be to choose a treatment that has been shown to be effective in reducing COPD exacerbations, while also considering the potential risks and benefits of each option.

From the Research

Treatment Options for Recurrent COPD Exacerbation

• For an 82-year-old man with recurrent COPD exacerbations, treatment options include medications such as long-acting beta-2 agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) 4.
• LABAs, such as salmeterol and formoterol, have been shown to improve dyspnea and reduce acute exacerbations, preventing about two hospital admissions per 100 patients with moderate to severe COPD treated for 7 months 4.
• LAMAs, such as tiotropium, have symptomatic efficacy in COPD, reducing dyspnea and acute exacerbations, and have been extensively evaluated in clinical trials 4, 5.

Combination Therapy

• Combination therapy with a LAMA and a LABA has been shown to be effective in reducing exacerbations and hospitalizations in patients with COPD 6, 7, 8.
• The combination of tiotropium and olodaterol, a LAMA and a LABA, has been shown to be effective in reducing the risk of exacerbations and improving lung function and quality of life in patients with COPD 5, 8.
• Dual LABA/LAMA therapy has been shown to be superior to either LABA or LAMA monotherapy in reducing the risk of exacerbations and hospitalizations in patients with symptomatic COPD 7.

Safety and Efficacy

• Tiotropium has been shown to be safe and efficacious as a long-term, once-daily LAMA for the maintenance treatment of COPD and for reducing COPD exacerbations 5.
• The combination of tiotropium and olodaterol has been shown to be well-tolerated and effective in reducing exacerbations and improving lung function and quality of life in patients with COPD 8.
• Inhaled corticosteroids (ICS) can be associated with local and systemic adverse effects, and the use of dual bronchodilator therapy, such as a LABA and a LAMA, may be a preferred treatment option for patients with COPD 8.