What are the typical take-home medications for an adult patient with moderate to severe chronic obstructive pulmonary disease (COPD) and a history of smoking?

Take-Home Medications for Moderate to Severe COPD

For an adult patient with moderate to severe COPD and smoking history, prescribe combination long-acting bronchodilator therapy (LABA/LAMA) as the foundation of treatment, add inhaled corticosteroids if the patient has frequent exacerbations or elevated eosinophils, ensure smoking cessation pharmacotherapy, and provide both influenza and pneumococcal vaccinations. 1

Core Pharmacologic Therapy

Primary Maintenance Bronchodilators

Combination LABA/LAMA therapy is the standard of care for moderate to severe COPD with significant symptoms. 1, 2, 3

• Long-acting muscarinic antagonist (LAMA) combined with long-acting beta-2 agonist (LABA) provides superior symptom control and lung function improvement compared to monotherapy 1, 2
• Examples include tiotropium/olodaterol (Stiolto Respimat), umeclidinium/vilanterol, or glycopyrrolate/formoterol 4
• Administered once or twice daily depending on the specific combination product 1, 5
• This combination reduces dynamic hyperinflation, improves exercise tolerance, and decreases exacerbation frequency 1

Critical safety consideration: Avoid concurrent use of multiple LAMAs (e.g., do not combine Trelegy with nebulized Yupelri) as this increases anticholinergic adverse effects without additional benefit 6

Inhaled Corticosteroids (ICS) - Selective Use

Add ICS to LABA/LAMA (triple therapy) only in specific circumstances: 1, 5

• Patients with frequent exacerbations (≥2 per year or ≥1 requiring hospitalization) 1, 5
• Patients with elevated peripheral eosinophil counts (generally >300 cells/μL) 5
• Patients with rapid decline in FEV1 (>50 mL/year) 1

Important caveat: ICS increases pneumonia risk by approximately 4% compared to bronchodilators alone, so use judiciously 6

Rescue Bronchodilator

• Short-acting beta-2 agonist (SABA) such as albuterol for as-needed symptom relief 1, 2
• All patients must have rescue medication available regardless of maintenance therapy 4

Smoking Cessation Pharmacotherapy

Smoking cessation is the only intervention proven to modify disease progression and must be addressed aggressively. 1

First-line options (choose one):

• Varenicline - most effective for long-term quit rates 1
• Bupropion - alternative if varenicline not tolerated 1
• Nicotine replacement therapy (patch, gum, lozenge) - increases abstinence rates over placebo 1

These medications must be combined with behavioral counseling for maximum effectiveness - pharmacotherapy alone is insufficient 1

Vaccinations (Essential Preventive Therapy)

Influenza Vaccine

• Annual influenza vaccination reduces serious illness, mortality, exacerbations, and cardiovascular events 1
• Use killed or live inactivated virus formulations 1

Pneumococcal Vaccines

• PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) recommended for all patients ≥65 years 1
• For patients <65 years with moderate to severe COPD, consider pneumococcal vaccination based on individual risk 1

Additional Considerations for Severe Disease

Theophylline

• Consider adding theophylline (target serum level 5-15 μg/mL) if symptoms persist despite LABA/LAMA therapy 1
• Monitor closely for side effects including cardiac arrhythmias, GI upset, and drug interactions 1
• Generally reserved for patients who cannot tolerate or do not respond adequately to inhaled bronchodilators 1

Supplemental Oxygen

• Long-term oxygen therapy (LTOT) is the only treatment besides smoking cessation that improves survival in severe COPD 1
• Prescribe for patients with severe resting hypoxemia (SpO2 <89%) 1, 5
• Do not routinely prescribe for moderate desaturation without individualized assessment 1

Critical Medication Avoidance

Beta-blocking agents (including ophthalmic formulations) are absolutely contraindicated in all COPD patients as they antagonize bronchodilator therapy and cause bronchoconstriction 1, 6, 7

Inhaler Technique and Monitoring

• Assess inhaler technique at every visit - improper technique is a major cause of treatment failure 1
• Dry powder inhalers have lower error rates (10-40%) compared to metered-dose inhalers (76%) 6
• Review all concurrent anticholinergic medications to avoid excessive anticholinergic burden 6

Medications NOT Recommended

The following have insufficient evidence for routine use in COPD: 1, 2

• Montelukast (leukotriene receptor antagonist) - no supporting evidence for COPD 2
• Prophylactic antibiotics (continuous or intermittent) 1
• Mucolytics - variable trial results, not routinely recommended 1
• Pulmonary vasodilators for pulmonary hypertension 1