From the Guidelines
For a patient with COPD who has not used inhalers before, a long-acting bronchodilator (LABD) maintenance therapy is the best initial choice, as recommended by the 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1. This approach is focused on improving symptoms, reducing exacerbations, and mortality.
- The LABD can be a long-acting muscarinic antagonist (LAMA) or a long-acting beta-agonist (LABA), with the choice depending on the patient's specific needs and symptoms.
- For patients with moderate to severe dyspnea and/or poor health status, single inhaler dual therapy with LABD, such as LAMA/LABA, is recommended 1.
- It is essential to consider the patient's manual dexterity, coordination, and breathing capacity when selecting an inhaler device.
- Proper inhaler technique is crucial for medication effectiveness, and patients should receive thorough demonstration and practice with a healthcare provider.
- Regular follow-up within 4-6 weeks is important to assess symptom improvement, side effects, and technique.
- Additionally, rescue inhalers like albuterol should also be prescribed for breakthrough symptoms.
- The 2023 Canadian Thoracic Society guideline also suggests single-inhaler triple therapy in patients with persistent moderate to severe dyspnea and/or poor health status despite treatment with single inhaler dual therapy with LAMA/LABA or ICS/LABA 1.
From the Research
Initial Inhaler for COPD Patients
- The Global Initiative for Chronic Obstructive Lung Disease 2022 report recommends initial pharmacological treatment with a long-acting muscarinic antagonist (LAMA) or a long-acting β2-agonist (LABA) as monotherapy for most patients, or dual bronchodilator therapy (LABA/LAMA) in patients with more severe symptoms, regardless of exacerbation history 2.
- The American Thoracic Society treatment guidelines strongly recommend LABA/LAMA combination therapy over LAMA or LABA monotherapy in patients with COPD and dyspnea or exercise intolerance 2.
- Four fixed-dose combinations of a LAMA with a LABA are now available, all indicated as maintenance bronchodilator treatment to relieve symptoms in adult patients with COPD 3.
- LABA/LAMA fixed-dose combinations have shown benefits in lung function, dyspnea, and health status versus placebo and monotherapies 4.
- The combination of glycopyrronium and formoterol fumarate in an innovative pMDI-fixed dual combination offers a credible unique option to be given twice a day, providing an ICS-free alternative in COPD pharmacology 5.
Mechanisms of LABA and LAMA
- LABAs and LAMAs are widely used clinically as therapy for COPD, and have been shown to improve symptoms and lung function, and reduce exacerbation and hospitalization 6.
- LABAs act on orthosteric and allosteric sites on the β2-adrenergic receptors, while LAMAs act not only on orthosteric site on the muscarinic receptors, but also allosteric site on the β2-adrenergic receptors, leading to enhancing β2-adrenergic action 6.
- Allosteric GPCR modulation is involved in the synergistic effects between LABAs and LAMAs 6.