From the Guidelines
For a patient with moderate COPD and an FEV1 of 75%, the most appropriate daily medication to prescribe along with a short-acting beta2-agonist PRN would be an inhaled long-acting beta2-agonist (LABA) or a low-dose inhaled corticosteroid (ICS) in combination with a LABA, as these options have been shown to improve lung function, reduce symptoms, and decrease exacerbations in patients with moderate to severe COPD 1. The use of inhaled corticosteroids is recommended for patients with COPD who have a history of exacerbations or are at high risk for exacerbations, as they have been shown to reduce the frequency and severity of exacerbations 1. However, the most recent guidelines suggest that for patients with stable COPD at low risk of exacerbations, ICS/LABA combination therapy may be preferred over LAMA/LABA dual therapy in individuals with concomitant asthma, but for those without asthma, the choice between these therapies should be individualized based on symptom burden, health status, and risk of exacerbations 1. In patients with moderate COPD and no history of frequent exacerbations, a LABA may be a suitable initial choice, with the option to add an ICS if symptoms persist or if the patient experiences exacerbations 1. Oral corticosteroids and oral PDE-4 inhibitors are not recommended for daily use in patients with moderate COPD due to their potential side effects and the lack of evidence supporting their long-term benefits in this population 1. Key considerations in the management of COPD include:
- Reducing airway inflammation and preventing exacerbations
- Minimizing systemic side effects
- Individualizing treatment based on symptom burden, health status, and risk of exacerbations
- Considering combination therapy for patients with persistent symptoms or frequent exacerbations
- Avoiding oral corticosteroids and oral PDE-4 inhibitors for long-term management due to their side effects and limited benefits.
From the FDA Drug Label
Wixela Inhub® 250/50 is indicated for the twice-daily maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema. The recommended dosage for patients with COPD is 1 inhalation of Wixela Inhub® 250/50 twice daily, approximately 12 hours apart. If shortness of breath occurs in the period between doses, an inhaled, short-acting beta2-agonist should be taken for immediate relief
The NP should prescribe daily use of an Inhaled long-acting beta2-agonist, such as salmeterol, in addition to a short-acting beta2-agonist for Donnie's moderate COPD.
- Key points:
- The patient has moderate COPD with an FEV1 of 75%.
- The prescribed medication should be used for maintenance treatment of airflow obstruction.
- A short-acting beta2-agonist should be used as needed for immediate relief of shortness of breath. 2
From the Research
Treatment Options for COPD
Given Donnie's moderate COPD with an FEV1 of 75%, the treatment options can be evaluated as follows:
- Inhaled long-acting beta2-agonist: This is a recommended treatment for COPD, as stated in the study 3, which suggests that long-acting inhaled bronchodilators, including beta-2 agonists (LABA), are effective in regular treatment for the clinically stable phase of COPD.
- Low-dose inhaled corticosteroid: The study 4 compares fixed combinations of inhaled corticosteroids (ICS) and long-acting beta-agonists (LABA) for COPD treatment, suggesting that ICS/LABA combinations can be beneficial, but the specific choice may depend on various factors including exacerbation risk and side effect profiles.
- Oral corticosteroid: There is no direct evidence in the provided studies to support the use of oral corticosteroids as a daily treatment for moderate COPD. Oral corticosteroids are typically used for acute exacerbations of COPD.
- Oral PDE-4 inhibitor: Roflumilast, an oral PDE-4 inhibitor, is discussed in studies 5 and 6 as a treatment option for severe to very severe COPD, particularly for reducing exacerbations in patients with chronic bronchitis. However, its use is generally considered for more severe cases or in combination with other treatments for patients at high risk of exacerbations.
Key Considerations
When selecting a treatment, it's crucial to consider the severity of COPD, the patient's symptoms, history of exacerbations, and response to previous treatments, as well as potential side effects and interactions with other medications, as indicated by the studies 3, 7, 4, 5, and 6.