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

From the Guidelines

For patients with stable moderate to very severe COPD, maintenance combination inhaled corticosteroid/long-acting beta-agonist therapy is recommended compared with inhaled corticosteroid monotherapy to prevent acute exacerbations of COPD. This recommendation is based on the American College of Chest Physicians and Canadian Thoracic Society guideline 1. The goal of COPD therapy is to improve symptoms, reduce exacerbations, and slow disease progression.

Key Components of COPD Therapy

• Smoking cessation is the most effective intervention to slow COPD progression.
• Bronchodilators are first-line therapy, including short-acting beta-agonists (SABAs) like albuterol and long-acting bronchodilators such as long-acting beta-agonists (LABAs) like salmeterol or long-acting muscarinic antagonists (LAMAs) like tiotropium.
• For patients with frequent exacerbations or severe symptoms, combination therapy with LABA/LAMA or adding inhaled corticosteroids (ICS) like fluticasone/salmeterol is recommended.
• Pulmonary rehabilitation is crucial, involving exercise training, education, and behavioral interventions.
• Oxygen therapy is prescribed for patients with severe hypoxemia, typically at 1-3 L/min continuously.
• Vaccinations against influenza and pneumococcal disease are essential preventive measures.

Management of Acute Exacerbations

• Treatment includes increased bronchodilator use, systemic corticosteroids, and antibiotics if bacterial infection is suspected.
• Noninvasive mechanical ventilation is recommended for patients with acute or acute-on-chronic respiratory failure 1.
• Pulmonary rehabilitation should be initiated within 3 weeks after hospital discharge for patients hospitalized with a COPD exacerbation 1.

These interventions work by reducing airway inflammation, improving airflow, strengthening respiratory muscles, and preventing infections, collectively improving quality of life and reducing mortality in COPD patients. The most recent and highest quality study supports the use of combination inhaled corticosteroid/long-acting beta-agonist therapy for preventing acute exacerbations of COPD 1.

From the FDA Drug Label

1. 1 Maintenance Treatment of COPD STIOLTO RESPIMAT is a combination of tiotropium bromide and olodaterol indicated for long-term, once-daily maintenance treatment of patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema The recommended dosage of STIOLTO RESPIMAT is two inhalations once-daily at the same time of the day.

COPD Therapy:

• Tiotropium (INH) is indicated for long-term, once-daily maintenance treatment of patients with COPD, including chronic bronchitis and/or emphysema 2.
• Salmeterol (INH) is used in the treatment of subjects with COPD, with efficacy evaluated in 6 randomized, double-blind, parallel-group clinical trials in adult subjects aged 40 years and older 3.
• The recommended dosage of STIOLTO RESPIMAT, which contains tiotropium, is two inhalations once-daily at the same time of the day 2.
• Fluticasone propionate and salmeterol inhalation powder has been shown to improve lung function and reduce exacerbations in subjects with COPD 3.

From the Research

COPD Therapy Overview

• COPD is a respiratory disorder characterized by largely irreversible changes in air flow due to irritants such as tobacco smoke 4.
• Patients with COPD experience acute exacerbations, and severe disease may progress to chronic respiratory failure 4.

Medications for COPD

• Regular medication is not necessary for patients who do not have recurrent symptoms 4.
• Inhaled short-acting beta-2 agonists, such as salbutamol, can improve dyspnoea and are preferred by patients over placebo 5.
• Long-acting beta-2 agonists, such as salmeterol and formoterol, can reduce breathlessness and acute exacerbations 4.
• Inhaled long-acting antimuscarinic bronchodilators, such as tiotropium, have symptomatic efficacy in COPD, reducing dyspnoea and acute exacerbations 4.
• Combination of an antimuscarinic with an inhaled beta-2 agonist can improve symptoms in 7% to 10% of patients 4.
• Inhaled corticosteroids can be added to a long-acting beta-2 agonist to prevent exacerbations in patients with a history of one or more exacerbations per year 4, 6.

Treatment Recommendations

• The first measure in COPD is to eliminate exposure to the irritant, most often tobacco 4.
• Treatment should be adapted to symptoms and the frequency of exacerbations: a short-acting beta-2 agonist should be tried first, then replaced by an inhaled long-acting bronchodilator, or possibly tiotropium, when its effect is too short-lived 4.
• A strong recommendation 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 6.
• A conditional recommendation 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 6.

Safety and Efficacy

• Inhaled beta-2 agonists occasionally provoke cardiovascular disorders, but no excess mortality has been reported among the thousands of COPD patients included in clinical trials 4.
• Tiotropium, like other inhaled anti-muscarinics, has antimuscarinic adverse effects, including cardiac, visual, and buccal disorders 4.
• Glycopyrronium may carry a higher risk of serious cardiovascular effects 4.
• Short-acting bronchodilators may increase the risk of cardiac adverse events, particularly at higher doses 7.