What is the best course of action for a 68-year-old patient with shortness of breath (SOB), a history of chronic obstructive pulmonary disease (COPD) with emphysema, currently taking inhaled corticosteroid (ICS), long-acting beta-agonist (LABA), long-acting muscarinic antagonist (LAMA), and using albuterol and ipratropium nebulizers, with recent leukocytosis and impaired renal function, following two COPD exacerbations in the past month?

From the Guidelines

This patient requires hospitalization for a COPD exacerbation and should receive systemic corticosteroids, broad-spectrum antibiotics, and continued bronchodilator therapy. The elevated WBC count suggests infection, and her recent exacerbations indicate poor disease control. According to the 2017 GOLD report 1, systemic glucocorticoids in COPD exacerbations shorten recovery time and improve FEV1, and a dose of 40 mg prednisone per day for 5 days is recommended.

Given her frequent exacerbations, triple therapy with LABA/LAMA/ICS may be considered to reduce exacerbation risk 1. However, the increased risk of pneumonia associated with ICS should be weighed against the potential benefits. The patient's current medication regimen includes ICS, LABA, and LAMA, which is consistent with the GOLD recommendations for patients with frequent exacerbations.

Oxygen therapy should be provided to maintain saturation between 88-92%, but avoid hyperoxia which can worsen hypercapnia in COPD patients. Upon stabilization, smoking cessation counseling is essential, as continued smoking will accelerate lung function decline. Pulmonary rehabilitation should be considered after discharge, and her maintenance medications should be optimized. The slightly elevated BUN may indicate dehydration or early kidney dysfunction, so fluid status should be monitored.

The use of azithromycin or erythromycin for 1 year may reduce the risk of exacerbations in patients prone to exacerbations 1, but the potential benefits and risks should be carefully considered. Roflumilast may also be considered for patients with chronic bronchitis and frequent exacerbations, but its use is associated with more adverse effects than inhaled medications for COPD 1.

Overall, an aggressive approach is necessary given her frequent exacerbations, which are associated with accelerated disease progression and increased mortality risk. Close monitoring and optimization of her treatment plan are crucial to improve her outcomes and quality of life.

From the FDA Drug Label

The effect of roflumilast 500 mcg once daily on COPD exacerbations was evaluated in five 1-year trials (Trials 3,4,5,6 and 9). Two of the trials (Trials 3 and 4) conducted initially enrolled a population of patients with severe COPD (FEV 1 ≤50% of predicted) inclusive of those with chronic bronchitis and/or emphysema who had a history of smoking of at least 10 pack years In these trials, long-acting beta agonists and short-acting anti-muscarinics were allowed and were used by 44% and 35% of patients treated with roflumilast and 45% and 37% of patients treated with placebo, respectively. Trial 5 randomized a total of 1525 patients (765 on roflumilast) and Trial 6 randomized a total of 1571 patients (772 on roflumilast) In both trials, roflumilast 500 mcg once daily demonstrated a significant reduction in the rate of moderate or severe exacerbations compared to placebo

The patient has severe COPD with emphysema, and has had 2 COPD exacerbations in the last month. The patient is already taking a LABA, LAMA, ICS, and using albuterol and ipratropium neb.

• The use of roflumilast may be considered to reduce the rate of COPD exacerbations in this patient, as it has been shown to be effective in patients with severe COPD and a history of exacerbations 2.
• However, the patient's WBC and BUN levels should be monitored, as roflumilast may have adverse effects on these parameters.
• It is also important to note that roflumilast is not a rescue medication and should be used as an add-on therapy to the patient's current treatment regimen.

From the Research

Patient Profile

• 68-year-old patient with shortness of breath (SOB)
• Chain smoker with COPD and emphysema
• Currently taking ICS, LABA, LAMA, and using albuterol and ipratropium neb
• Experienced 2 COPD exacerbations in the last month
• WBC count is 14 and BUN is 20

Treatment Options

• According to 3, treatment for acute exacerbations of COPD includes oxygen, inhaled beta2 agonists, inhaled anticholinergics, antibiotics, and systemic corticosteroids
• 4 suggests that treatments for severe AECOPD aim to minimize the negative impact of the current exacerbation and prevent subsequent events
• 5 recommends acute management interventions such as corticosteroids or antibiotics and measures to support the respiratory system, including non-invasive ventilation (NIV)

Management of COPD Exacerbations

• 6 states that timely and appropriate maintenance pharmacotherapy, particularly dual bronchodilators, can significantly reduce exacerbations in patients with COPD
• 7 provides a comprehensive review of therapeutic interventions for managing COPD exacerbations, including pharmacologic and non-pharmacologic strategies
• Management of COPD exacerbations is crucial to prevent complications, as COPD exacerbations are associated with increased healthcare costs and decreased quality of life 7

Potential Interventions

• Consideration of antibiotic therapy, as the patient's WBC count is elevated, suggesting a potential infection 3, 4
• Use of systemic corticosteroids to reduce airway inflammation 3, 5
• Implementation of non-pharmacologic interventions, such as oxygen therapy, pulmonary rehabilitation, and smoking cessation, to support the patient's respiratory system and improve overall health 4, 7