What is the typical prescription for a patient with Chronic Obstructive Pulmonary Disease (COPD)?

COPD Prescription Management

For patients with COPD, initiate treatment with a long-acting muscarinic antagonist (LAMA) such as glycopyrrolate combined with a long-acting beta-agonist (LABA) as first-line therapy for those with significant symptoms or exacerbation risk, as this combination provides superior exacerbation prevention and symptom control compared to monotherapy or LABA/ICS combinations. 1

Initial Pharmacologic Approach by Disease Severity

Mild COPD (FEV1 60-80% predicted)

• Start with short-acting bronchodilators as needed: either a short-acting beta-2 agonist (salbutamol 2.5-5 mg) or short-acting anticholinergic (ipratropium 0.25-0.5 mg) based on symptomatic response 2
• Patients typically have smoker's cough with little breathlessness and no abnormal signs 2

Moderate COPD (FEV1 40-59% predicted)

• Escalate to regular long-acting bronchodilator therapy: LAMA or LABA as monotherapy 2
• If choosing single agent, prefer LAMA (glycopyrrolate) over LABA for superior exacerbation prevention and reduced hospitalizations 1
• Consider corticosteroid trial (prednisolone 30 mg daily for 2 weeks with pre/post spirometry) - only 10-20% show objective improvement defined as FEV1 increase ≥200 ml and ≥15% from baseline 2
• Combination of short-acting beta-2 agonist plus anticholinergic may be needed for adequate symptom control 2

Severe COPD (FEV1 <40% predicted)

• Initiate LABA/LAMA combination therapy immediately (e.g., glycopyrrolate/formoterol or glycopyrrolate/indacaterol) 1, 3
• This represents the preferred first-line approach for Group D patients (high symptom burden and exacerbation risk) 1
• LABA/LAMA combinations produce superior patient-reported outcomes compared to single bronchodilators 1
• LABA/LAMA is superior to LABA/ICS for preventing exacerbations in severe COPD 1

Key Prescribing Principles

Bronchodilator Selection

• Long-acting agents are superior to short-acting agents for routine management 2
• Anticholinergic agents (ipratropium, tiotropium, glycopyrrolate) are more effective in COPD than in asthma 2
• Beta-2 agonists provide bronchodilation within minutes, peaking at 15-30 minutes, lasting 4-5 hours for short-acting formulations 2
• Anticholinergics have slower onset (30-90 minutes) but longer duration: 4-6 hours for ipratropium, 6-8 hours for oxitropium 2
• At submaximal doses, combining anticholinergics with beta-2 agonists produces additive effects 2

Inhaled Corticosteroid Considerations

• Avoid ICS as initial therapy unless asthma-COPD overlap or elevated blood eosinophils present 1
• ICS increases pneumonia risk without superior exacerbation prevention compared to LABA/LAMA 1
• Only add ICS if patient demonstrates objective spirometric improvement (FEV1 increase ≥200 ml and ≥15% baseline) during trial 2
• For COPD with chronic bronchitis and FEV1 <50% predicted, consider LABA/ICS combination 2

Delivery Device Selection

• Inhaled route preferred over oral/parenteral - results in fewer adverse effects 2
• Options include metered-dose inhalers (with/without spacers), breath-actuated inhalers, and dry-powder devices 2
• Teach proper technique at first prescription and verify periodically 2
• During acute exacerbations, nebulizers may be easier for breathless patients, though metered-dose inhalers with spacers are equally effective 2

Acute Exacerbation Management

Bronchodilators for Exacerbations

• Administer short-acting inhaled beta-2 agonists with or without short-acting anticholinergics as initial treatment 2
• Nebulized bronchodilators at 4-6 hourly intervals (may use more frequently if needed) 2
• For severe exacerbations or poor response to monotherapy, combine both agents 2
• Intravenous methylxanthines NOT recommended due to side effects 2

Systemic Corticosteroids

• Prescribe 40 mg prednisone daily for 5 days (or 100 mg hydrocortisone IV if oral route unavailable) 2
• Systemic steroids shorten recovery time, improve FEV1 and oxygenation, reduce early relapse and treatment failure 2
• Duration should not exceed 5-7 days 2
• Oral prednisolone equally effective as intravenous administration 2
• May be less effective in patients with lower blood eosinophil levels 2

Antibiotics

• Indicated when sputum becomes purulent - treat empirically for 7-14 days (or 5-7 days per newer guidelines) 2
• Most common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, viruses 2
• First-line options: amoxicillin, tetracycline derivatives, amoxicillin/clavulanic acid 2
• Alternative treatments: newer cephalosporins, macrolides, quinolones 2
• Patients may keep antibiotics in reserve to start when symptoms suggest infection 2
• No advantage to prophylactic or aerosolized therapy except in selected patients with frequent winter infections 2

Essential Non-Pharmacologic Interventions

Smoking Cessation

• Smoking cessation is mandatory at all disease stages - cannot restore lost function but prevents accelerated decline 2
• Participation in active cessation programs with nicotine replacement therapy yields higher sustained quit rates 2
• Temporary nicotine replacement (gum or transdermal) plus behavioral intervention increases success 2

Vaccinations

• Influenza vaccination recommended for all COPD patients 2
• Pneumococcal vaccines (PCV13 and PPSV23) recommended for patients ≥65 years 2
• PPSV23 also recommended for younger patients with significant comorbidities including chronic heart or lung disease 2

Oxygen Therapy

• Long-term oxygen indicated for stable patients with:
  • PaO2 ≤55 mmHg (7.3 kPa) or SaO2 ≤88% confirmed twice over 3 weeks, OR 2
  • PaO2 55-60 mmHg (7.3-8.0 kPa) or SaO2 88% with pulmonary hypertension, peripheral edema, or polycythemia (hematocrit >55%) 2

Common Pitfalls to Avoid

• Do not prescribe LABA monotherapy without ICS in asthma - associated with increased asthma-related death (not applicable to COPD) 4
• Do not use theophyllines routinely - limited value with narrow therapeutic index and significant side effects 2
• Do not continue systemic corticosteroids beyond 7-14 days after acute exacerbation unless proven effective when stable 2
• Do not assume spirometric response predicts symptomatic benefit - improvement in symptoms and functional capacity can occur without spirometric changes 2
• Do not use intravenous route for beta-2 agonists in most acute exacerbations - offers no advantage 2