What are the available brands and combinations of drugs for the treatment of Chronic Obstructive Pulmonary Disease (COPD) in the Indian market?

COPD Treatment: Available Brands and Drug Combinations in the Indian Market

Core Bronchodilator Therapy

For COPD management in India, start with long-acting bronchodilators as the foundation of treatment, with LABA/LAMA combinations being the preferred initial therapy for most symptomatic patients, particularly those with frequent exacerbations. 1

Single Agent Long-Acting Bronchodilators

Long-Acting Muscarinic Antagonists (LAMAs):

• Tiotropium (Spiriva, Tiova, Tiogiva) - 18 mcg once daily via HandiHaler or Respimat 1, 2
• Glycopyrronium (Seebri) - 50 mcg once daily 1
• Aclidinium (Eklira, Bretaris) - 400 mcg twice daily 3
• Umeclidinium (Incruse) - 62.5 mcg once daily 1

Long-Acting Beta-2 Agonists (LABAs):

• Formoterol (Foracort, Symbicort) - 12 mcg twice daily 4, 5
• Salmeterol (Serevent) - 50 mcg twice daily 6
• Indacaterol (Onbrez, Hirobriz) - 150-300 mcg once daily 7
• Olodaterol (Striverdi) - 5 mcg once daily 8

Dual Bronchodilator Combinations (LABA/LAMA)

These combinations are superior to monotherapy for preventing exacerbations and improving lung function, and are preferred over LABA/ICS combinations for most COPD patients due to lower pneumonia risk. 1

Available LABA/LAMA Fixed-Dose Combinations:

• Tiotropium/Olodaterol (Stiolto Respimat, Spiolto) - 2.5/2.5 mcg, two inhalations once daily 8
• Glycopyrronium/Indacaterol (Ultibro Breezhaler) - 50/110 mcg once daily 1, 7
• Umeclidinium/Vilanterol (Anoro Ellipta) - 62.5/25 mcg once daily 1
• Aclidinium/Formoterol (Duaklir) - 400/12 mcg twice daily 1, 7
• Glycopyrronium/Formoterol (Bevespi) - available in some markets 1

Triple Therapy (LABA/LAMA/ICS)

Add inhaled corticosteroids to LABA/LAMA therapy only in patients with persistent exacerbations despite dual bronchodilator therapy, or those with features suggesting asthma-COPD overlap (elevated eosinophils, significant reversibility). 1

Available Triple Therapy Combinations:

• Fluticasone Furoate/Umeclidinium/Vilanterol (Trelegy Ellipta) - 100/62.5/25 mcg once daily 1
• Beclomethasone/Glycopyrronium/Formoterol (Trimbow) - 87/9/5 mcg, two inhalations twice daily

LABA/ICS Combinations (when triple therapy needed but no single-inhaler option):

• Fluticasone/Salmeterol (Seretide, Seroflo) - 250/50 mcg or 500/50 mcg twice daily 1
• Budesonide/Formoterol (Symbicort, Foracort) - 200/6 mcg or 400/6 mcg twice daily 5
• Fluticasone Furoate/Vilanterol (Relvar) - 100/25 mcg or 200/25 mcg once daily 1

Short-Acting Bronchodilators (Rescue Therapy)

All patients should have short-acting bronchodilators available for acute symptom relief, regardless of maintenance therapy. 1

• Salbutamol/Albuterol (Asthalin, Ventolin) - 100 mcg MDI, 2 puffs as needed 1
• Levosalbutamol (Levolin) - 50 mcg MDI, 2 puffs as needed
• Ipratropium (Atrovent) - 20 mcg MDI, 2 puffs as needed 1
• Ipratropium/Salbutamol (Duolin, Combivent) - 20/100 mcg, 2 puffs as needed 6

Additional Pharmacotherapy

Phosphodiesterase-4 Inhibitor:

• Roflumilast (Daxas) - 500 mcg once daily, reserved for patients with FEV1 <50% predicted, chronic bronchitis, and persistent exacerbations despite LABA/LAMA/ICS therapy 1

Methylxanthines:

• Theophylline SR (Deriphyllin, Phyllocontin) - 200-400 mg twice daily, provides modest bronchodilation but requires monitoring for side effects and drug interactions 1

Antibiotics for Exacerbations

Use antibiotics empirically when exacerbations present with increased sputum purulence plus either increased dyspnea or increased sputum volume. 1

First-line options (7-14 day course):

• Amoxicillin - 500 mg three times daily 1
• Amoxicillin-Clavulanate (Augmentin) - 625 mg three times daily 1
• Doxycycline - 100 mg twice daily 1

Alternative options for treatment failure or resistant organisms:

• Azithromycin - 500 mg once daily for 3 days or 500 mg day 1, then 250 mg days 2-5 1
• Levofloxacin - 500 mg once daily 1
• Moxifloxacin - 400 mg once daily 1

Chronic macrolide therapy (Azithromycin 250-500 mg three times weekly) may be considered in former smokers with persistent exacerbations despite optimal therapy, though risk of bacterial resistance must be weighed. 1

Systemic Corticosteroids for Exacerbations

Prednisolone 30-40 mg daily for 5-7 days during acute exacerbations improves recovery time and lung function. 1

Long-term oral corticosteroids are NOT recommended due to unfavorable risk-benefit ratio. 1

Vaccinations

Influenza vaccine annually and pneumococcal vaccines (PCV13 followed by PPSV23) are recommended for all COPD patients, particularly those ≥65 years. 1

Clinical Pearls and Caveats

• LAMAs have greater effect on exacerbation reduction compared to LABAs and should be preferred if choosing monotherapy 1
• ICS increases pneumonia risk in COPD; avoid as monotherapy and reserve for appropriate indications 1
• Combination LABA/LAMA reduces exacerbations more effectively than LABA/ICS 1
• Ensure proper inhaler technique at every visit; device selection should match patient's inspiratory capacity and dexterity 1
• Nebulizers are rarely needed in stable COPD; reserve for acute exacerbations or patients unable to use standard inhalers despite optimization 1
• Statins are NOT recommended for COPD exacerbation prevention 1
• Monitor for anticholinergic side effects (dry mouth, urinary retention, narrow-angle glaucoma) especially in elderly patients on LAMA therapy 8, 3, 8