What is the treatment for Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

From the Guidelines

Treatment for COPD exacerbation should involve a combination of bronchodilators, corticosteroids, and antibiotics when appropriate, with the goal of minimizing morbidity, mortality, and improving quality of life. The most recent and highest quality study, 1, recommends that treatment decisions be based on clinical judgment and patient preferences and values, and involve shared decision-making by the patient and clinician.

Key Components of Treatment

• Short-acting bronchodilators like albuterol (2-4 puffs every 4-6 hours) or ipratropium (2 puffs every 6 hours) are first-line treatments to relieve acute bronchospasm, as recommended by 1.
• Systemic corticosteroids such as prednisone (40mg daily for 5 days) help reduce inflammation and speed recovery, with evidence from 1 showing improved symptom resolution and clinical cure rates.
• Antibiotics are added when there are signs of bacterial infection, with common choices including amoxicillin-clavulanate (875/125mg twice daily for 5-7 days), azithromycin (500mg on day 1, then 250mg daily for 4 days), or doxycycline (100mg twice daily for 5-7 days), as suggested by 1.
• Supplemental oxygen should be provided to maintain oxygen saturation above 88-92%, as recommended by 1.

Additional Considerations

• For severe exacerbations, hospitalization may be necessary for more intensive treatment including nebulized bronchodilators, intravenous corticosteroids, and possibly non-invasive ventilation, as recommended by 1.
• After the acute phase, patients should receive education on proper inhaler technique, smoking cessation counseling if applicable, and a review of maintenance therapy to prevent future exacerbations, as suggested by 1.
• The use of non-invasive mechanical ventilation is recommended for patients with acute or acute-on-chronic respiratory failure, as stated in 1.

Guiding Principles

• Treatment should be individualized based on the severity of the exacerbation, patient preferences, and comorbidities, as recommended by 1.
• The goal of treatment is to minimize morbidity, mortality, and improve quality of life, with a focus on reducing airway inflammation, relaxing bronchial smooth muscle, and clearing infections that can worsen COPD symptoms, as stated in 1.

From the FDA Drug Label

Adult PatientsAcute Bacterial Exacerbations of Chronic Obstructive Pulmonary Disease In a randomized, double-blind controlled clinical trial of acute exacerbation of chronic bronchitis (AECB), azithromycin (500 mg once daily for 3 days) was compared with clarithromycin (500 mg twice daily for 10 days). The primary endpoint of this trial was the clinical cure rate at Day 21 to 24 For the 304 patients analyzed in the modified intent to treat analysis at the Day 21 to 24 visit, the clinical cure rate for 3 days of azithromycin was 85% (125/147) compared to 82% (129/157) for 10 days of clarithromycin The following outcomes were the clinical cure rates at the Day 21 to 24 visit for the bacteriologically evaluable patients by pathogen: PathogenAzithromycin (3 Days) Clarithromycin (10 Days) S. pneumoniae29/32 (91%)21/27 (78%) H. influenzae12/14 (86%)14/16 (88%) M catarrhalis11/12 (92%)12/15 (80%)

The treatment of COPD exacerbation with azithromycin has a clinical cure rate of 85% at Day 21 to 24. The most effective treatment should be chosen based on the pathogen involved. Azithromycin is effective against S. pneumoniae, H. influenzae, and M. catarrhalis. 2

WARNINGS The use of ipratropium bromide inhalation solution as a single agent for the relief of bronchospasm in acute COPD exacerbation has not been adequately studied. Drugs with faster onset of action may be preferable as initial therapy in this situation.

Ipratropium may not be the best initial choice for COPD exacerbation due to its slower onset of action. 3

From the Research

COPD Exacerbation Treatment

• The treatment of COPD exacerbations typically includes bronchodilators, corticosteroids, and antibiotics 4.
• Strong evidence exists for the benefit of corticosteroids for exacerbations and of antibiotics in the acute hospital setting 4.
• Combination therapy with albuterol and ipratropium bromide is also used in the treatment of COPD, providing better improvement in airflow than either component alone 5.

Pharmacologic Management

• The American Thoracic Society recommends the use of long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy in patients with COPD and dyspnea or exercise intolerance 6.
• Triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA is conditionally recommended over dual therapy with LABA/LAMA in patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year 6.

Azithromycin Treatment

• Low-dose azithromycin has been shown to reduce the number of exacerbations in patients with COPD, and is recommended for patients with frequent exacerbations 7.
• Azithromycin therapy is most effective in patients with COPD with frequent exacerbations in GOLD 1 and 2 and GOLD C, as well as in patients with blood eosinophilia over 2% 7.