From the Guidelines
The most appropriate additional therapy for this 62-year-old man with COPD is smoking cessation (option D). This recommendation is based on the fact that smoking cessation is the single most effective intervention for patients with COPD who continue to smoke, as it directly addresses the underlying cause of the disease and can significantly slow disease progression, improve symptoms, and reduce exacerbation risk 1. While the patient is already on appropriate maintenance therapy with salmeterol and tiotropium, his continued smoking of one pack daily with a 40-pack-year history is a significant concern that needs to be addressed to improve his outcomes. Key points to consider in this patient's management include:
- The patient's moderate airflow limitation (FEV1 62% predicted) and symptoms such as breathlessness on inclines, which suggest a GOLD B classification, indicating that while his current medications are appropriate, addressing the underlying cause of his COPD through smoking cessation is essential.
- The potential benefits of smoking cessation in improving the effectiveness of his current bronchodilator therapy, exercise tolerance, and quality of life more than any other intervention at this stage.
- The lack of evidence supporting the use of chronic azithromycin therapy, prednisone, or pulmonary rehabilitation as the first-line additional therapy in this patient's specific context, especially considering the potential side effects and the fact that the patient has not been hospitalized or seen urgently for an exacerbation 1. Therefore, prioritizing smoking cessation as the most appropriate additional therapy aligns with the goal of improving morbidity, mortality, and quality of life for this patient.
From the FDA Drug Label
Varenicline was evaluated in a randomized, double-blind, placebo-controlled study of subjects aged ≥ 35 years with mild-to-moderate COPD with post-bronchodilator FEV1/FVC <70% and FEV1 ≥ 50% of predicted normal value Subjects treated with varenicline had a superior rate of CO-confirmed abstinence during weeks 9 through 12 (41%) compared to subjects treated with placebo (9%) and from week 9 through 52 (19%) compared to subjects treated with placebo (6%)
The most appropriate additional therapy for the 62-year-old man with COPD is D Smoking cessation. The patient has a 40-pack-year history of smoking and continues to smoke one pack daily, which exacerbates his COPD. Varenicline, a smoking cessation aid, has been shown to be effective in patients with COPD, with a superior rate of CO-confirmed abstinence compared to placebo 2.
From the Research
Additional Therapy for COPD Patient
The patient in question has a 40-pack-year history of smoking and continues to smoke one pack daily, despite having COPD. The most appropriate additional therapy for this patient would be:
- D Smoking cessation: This is the most effective strategy for slowing down the progression of COPD and reducing mortality in patients who continue to smoke 3, 4, 5, 6, 7.
Rationale
The evidence suggests that smoking cessation is crucial for patients with COPD, and various pharmacological and behavioral interventions can aid in this process. Studies have shown that nicotine replacement therapy, bupropion, and varenicline can be effective in promoting smoking cessation in patients with COPD 3, 4, 6, 7. Additionally, combination pharmacotherapy and behavioral interventions can increase the chances of successful smoking cessation 5, 7.
Other Options
The other options are not the most appropriate additional therapy for this patient:
- A Chronic azithromycin therapy: There is no evidence to suggest that chronic azithromycin therapy is beneficial for COPD patients who continue to smoke.
- B Prednisone: Prednisone is not typically used as a long-term treatment for COPD, and its use is usually reserved for acute exacerbations.
- C Pulmonary rehabilitation: While pulmonary rehabilitation can be beneficial for COPD patients, it is not the most appropriate additional therapy for a patient who continues to smoke, as smoking cessation is the primary goal.