What treatment is indicated for a patient with two Chronic Obstructive Pulmonary Disease (COPD) exacerbations within a 2-week period?

From the Guidelines

For a patient experiencing two COPD exacerbations within 2 weeks, I recommend intensifying therapy with a combination of short-term systemic corticosteroids, antibiotics if indicated, and optimization of bronchodilator therapy. Start with oral prednisone 40mg daily for 5 days, as systemic glucocorticoids have been shown to shorten recovery time and improve FEV1 in COPD exacerbations 1. If the patient shows signs of infection (increased sputum purulence, fever), add an appropriate antibiotic such as azithromycin 500mg on day 1 followed by 250mg daily for 4 more days, or amoxicillin-clavulanate 875/125mg twice daily for 5-7 days, considering the most common organisms involved in COPD exacerbations are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and viruses 1. Ensure the patient is using short-acting bronchodilators like albuterol 2-4 puffs every 4-6 hours as needed. Optimize maintenance therapy with a long-acting muscarinic antagonist (LAMA) like tiotropium 18mcg daily and a long-acting beta-agonist (LABA) plus inhaled corticosteroid combination like fluticasone/salmeterol 250/50mcg twice daily, as combination therapy has proven beneficial for lung function and health-related quality of life 1. Consider adding roflumilast 500mcg daily if the patient has chronic bronchitis and frequent exacerbations, as it reduces moderate and severe exacerbations treated with systemic corticosteroids in such patients 1. After stabilization, the patient should be evaluated for potential triggers, adherence issues, proper inhaler technique, and comorbidities, and may need referral to a pulmonologist for consideration of additional therapies such as azithromycin prophylaxis or evaluation for pulmonary rehabilitation, given that frequent exacerbations indicate poor disease control and are associated with accelerated lung function decline 1.

Some key points to consider in the management of this patient include:

• The importance of short-term systemic corticosteroids in reducing the severity and duration of exacerbations
• The role of antibiotics in treating exacerbations with signs of infection
• The optimization of bronchodilator therapy to improve lung function and reduce symptoms
• The potential benefits of adding roflumilast for patients with chronic bronchitis and frequent exacerbations
• The need for comprehensive evaluation and potential referral to a specialist for further management and prevention of future exacerbations.

From the FDA Drug Label

The primary efficacy variable in both trials was the annual rate of moderate/severe exacerbations. Patients treated with BREO ELLIPTA 100/25 mcg had a lower annual rate of moderate/severe COPD exacerbations compared with vilanterol in both trials (Table 7).

The treatment to give a patient with two COPD exacerbations in 2 weeks is BREO ELLIPTA 100/25 mcg, as it has been shown to have a lower annual rate of moderate/severe COPD exacerbations compared to vilanterol alone 2.

• Key points:
  • BREO ELLIPTA 100/25 mcg is a combination of fluticasone furoate and vilanterol.
  • It has been shown to reduce the rate of moderate and severe COPD exacerbations.
  • The patient's history of two COPD exacerbations in 2 weeks suggests a need for a treatment that can help reduce the frequency of exacerbations.

From the Research

Treatment Options for COPD Exacerbations

• For a patient with two COPD exacerbations in 2 weeks, treatment options should focus on managing symptoms and reducing the risk of further exacerbations 3, 4.
• Long-acting inhaled bronchodilator medications, including long-acting muscarinic antagonists (LAMA) and long-acting β2-agonists (LABA), are recommended as initial maintenance therapy for many patients with COPD 3, 5.
• Combinations of LAMA and LABA have been shown to lead to greater improvements in lung function and symptoms than LAMA monotherapy or ICS/LABA treatment 3, 4.
• Triple combination therapy, including an inhaled corticosteroid (ICS), LABA, and LAMA, may be considered for patients with frequent exacerbations and high levels of blood eosinophils 6.

Management of COPD Exacerbations

• Targeted O2 therapy should be titrated to an SpO2 of 88-92% to improve outcomes 7.
• Inhaled short-acting bronchodilators can be provided by various devices, including nebulizers, pressurized metered-dose inhalers, and dry powder inhalers 7.
• Noninvasive ventilation (NIV) is standard therapy for patients with COPD exacerbation and is supported by clinical practice guidelines 7.
• Management of auto-PEEP is a priority in mechanically ventilated patients with COPD, and can be achieved by reducing airway resistance and decreasing minute ventilation 7.

Considerations for Treatment

• The choice of treatment should be based on the individual patient's needs and medical history 3, 4.
• Patients with COPD should be closely monitored for signs of exacerbation and adjusted treatment as needed 7.
• Care coordination and evidence-based practices can improve outcomes in patients with COPD exacerbation 7.