What is the optimal inhaler regimen for a patient with chronic obstructive pulmonary disease (COPD) experiencing an acute exacerbation with influenza pneumonia, currently on fluticasone furoate-vilanterol (Breo) puffer and umeclidinium (Incruse) puffer?

From the Guidelines

For a COPD patient with an acute exacerbation and influenza pneumonia who is on fluticasone furoate-vilanterol and umeclidinium at home, the optimal puffer regimen would be to start a short-acting bronchodilator like salbutamol (albuterol) 100 mcg, 2-4 puffs every 4-6 hours as needed, and ipratropium bromide 20 mcg, 2-4 puffs every 4-6 hours as needed, while continuing the long-acting medications (fluticasone furoate-vilanterol and umeclidinium) unless the patient is severely ill or unable to use inhalers effectively. The patient's current long-acting medications provide ongoing anti-inflammatory and bronchodilator effects that complement the short-acting agents, and should be continued to maximize bronchodilation through multiple mechanisms while maintaining anti-inflammatory effects, which is crucial for managing both the COPD exacerbation and influenza pneumonia components of the illness 1. Some key points to consider in the management of COPD exacerbations include:

• The goal for treatment of exacerbations is to minimize the negative impact of the current exacerbation and to prevent subsequent events 1
• Short-acting inhaled β2-agonists, with or without short-acting anticholinergics, are recommended as the initial bronchodilators to treat an acute exacerbation 1
• Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge 1
• Systemic corticosteroids improve lung function (FEV1) and oxygenation and shorten recovery time and hospitalization duration, and should be added to the regimen 1
• Antibiotics, when indicated, shorten recovery time and reduce the risk of early relapse, treatment failure, and hospitalization duration, and should also be added to the regimen 1. The European Respiratory Society/American Thoracic Society guideline also recommends inhaled bronchodilator therapy for patients having a COPD exacerbation, as well as supplemental oxygen for hypoxaemic patients, and provides guidance on the use of systemic steroids, antibiotic therapy, noninvasive mechanical ventilation (NIV) and home-based management 1.

From the FDA Drug Label

Not for Acute Symptoms Inform patients that ANORO ELLIPTA is not meant to relieve acute symptoms of COPD and extra doses should not be used for that purpose. Advise patients to treat acute symptoms with an inhaled, short-acting beta2-agonist such as albuterol.

The optimal puffer regimen for acute COPD exacerbation in this patient would be to start a short-acting beta2-agonist such as albuterol for acute symptom relief.

• The patient should continue their current fluticasone furoate-vilanterol puffer as it contains an inhaled corticosteroid (ICS) which is beneficial for reducing inflammation.
• The patient should hold their umeclidinium puffer as the label does not provide information on the use of umeclidinium in acute COPD exacerbations, and the patient is already on a long-acting muscarinic antagonist (LAMA) and a long-acting beta2-agonist (LABA) combination (fluticasone furoate-vilanterol). 2

From the Research

Optimal Puffer Regimen for Acute COPD/Influenza Pneumonia

The optimal puffer regimen for a COPD patient experiencing an acute exacerbation, particularly with influenza pneumonia, involves adjusting their current medication to manage the exacerbation effectively.

• Short-acting puffers: For immediate relief during an exacerbation, short-acting bronchodilators such as short-acting beta-agonists (SABAs) or short-acting muscarinic antagonists (SAMAs) can be used as needed 3.
• Long-acting puffers adjustment: The patient is already on fluticasone furoate-vilanterol and umeclidinium, which are long-acting. During an exacerbation, the use of these medications may need to be adjusted or supplemented with other treatments such as systemic corticosteroids to reduce inflammation 4, 3.

Considerations for Adjusting Current Medication

• Systemic corticosteroids: These are often used in the treatment of acute COPD exacerbations to reduce airway inflammation 3.
• Antibiotics: If the exacerbation is suspected to be caused by a bacterial infection, antibiotics may be prescribed 3.
• Influenza treatment: If the patient has influenza pneumonia, antiviral medications may be indicated, depending on the severity and timing of the infection.

Long-term Management

After the acute exacerbation is managed, the patient's long-term medication regimen may need to be reassessed.

• Triple therapy: For patients with a history of frequent exacerbations, despite being on dual therapy (e.g., LABA/LAMA or LABA/ICS), moving to a triple therapy regimen (LABA/LAMA/ICS) could be considered, especially if blood eosinophils are elevated 5, 3.
• Monitoring and adjustment: Regular monitoring of the patient's condition and adjustment of their medication regimen as necessary to prevent future exacerbations and manage symptoms effectively 6, 7.