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

From the Guidelines

For COPD exacerbation treatment, a combination of bronchodilators, corticosteroids, and antibiotics is typically recommended, with the goal of minimizing morbidity, mortality, and improving quality of life. The most recent and highest quality study, 1, published in 2021, recommends prescribing systemic antibiotics for adults with acute exacerbations of COPD to improve clinical cure and reduce clinical failure.

Key Medications

• Short-acting bronchodilators like albuterol (2-4 puffs every 4-6 hours) or ipratropium (2 puffs every 6 hours) provide immediate relief by relaxing airway muscles, as recommended by 1 and 1.
• Systemic corticosteroids such as prednisone (40mg daily for 5 days) reduce inflammation, as stated in 1 and 1.
• Antibiotics are added when bacterial infection is suspected, with options including amoxicillin-clavulanate (875/125mg twice daily for 5-7 days), azithromycin (500mg day 1, then 250mg daily for 4 days), or doxycycline (100mg twice daily for 5-7 days), as recommended by 1.

Additional Treatments

• Oxygen therapy should be provided to maintain oxygen saturation above 88-92%, as part of standard care.
• For severe exacerbations, hospitalization may be necessary for more intensive treatment including nebulized medications, intravenous steroids, and ventilatory support, as indicated by 1 and 1.
• After the acute phase, maintenance therapy should be optimized with long-acting bronchodilators and inhaled corticosteroids as appropriate, to reduce airway inflammation, improve airflow, and prevent subsequent exacerbations, as recommended by 1 and 1.

Ventilatory Support

• Noninvasive ventilation (NIV) should be the first mode of ventilation used to treat acute respiratory failure, as stated in 1 and 1, to improve gas exchange, reduce work of breathing, and decrease hospitalization duration.

From the FDA Drug Label

The effect of roflumilast 500 mcg once daily on COPD exacerbations was evaluated in five 1-year trials (Trials 3,4,5,6 and 9). Two of the trials (Trials 3 and 4) conducted initially enrolled a population of patients with severe COPD (FEV 1 ≤50% of predicted) inclusive of those with chronic bronchitis and/or emphysema who had a history of smoking of at least 10 pack years Trial 5 randomized a total of 1525 patients (765 on roflumilast) and Trial 6 randomized a total of 1571 patients (772 on roflumilast) In both trials, roflumilast 500 mcg once daily demonstrated a significant reduction in the rate of moderate or severe exacerbations compared to placebo (Table 2).

Medications for COPD Exacerbation:

• Roflumilast 500 mcg once daily has been shown to reduce the rate of moderate or severe COPD exacerbations in patients with severe COPD associated with chronic bronchitis and a history of exacerbations.
• The evidence is based on two clinical trials (Trial 5 and Trial 6) that demonstrated a significant reduction in the rate of moderate or severe exacerbations compared to placebo 2 2.
• Key Points:
  • Roflumilast is used for the reduction of COPD exacerbations.
  • The medication has been evaluated in several clinical trials.
  • It is recommended for patients with severe COPD and a history of exacerbations.

From the Research

COPD Exacerbation Medications

• The pharmacotherapy of COPD exacerbations includes bronchodilators, corticosteroids, and antibiotics 3.
• Strong evidence exists for the benefit of corticosteroids for exacerbations and of antibiotics in the acute hospital setting 3.
• Management of COPD exacerbations in primary care includes use of short-acting bronchodilators if mild, and antibiotics and a short course of oral prednisolone if moderate/severe 4.
• Combination therapy with albuterol and ipratropium bromide is more effective than either agent alone in the treatment of COPD 5, 6.
• The combined formulation of albuterol and ipratropium bromide provides better improvement in airflow than either component alone and simplifies therapy and improves compliance compared with the individual components 6.
• A strong recommendation exists for 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 7.
• A conditional recommendation exists for the use of triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA 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 7.