From the Guidelines
The combination of prednisone 40mg daily, DuoNebs (albuterol/ipratropium), Trelegy (fluticasone/umeclidinium/vilanterol), and azithromycin (Z-pack) is an appropriate regimen for treating a COPD exacerbation, as it targets inflammation, airway constriction, and infection simultaneously, and is supported by the most recent and highest quality evidence 1.
Treatment Rationale
The use of prednisone 40mg daily for 5-7 days is recommended for COPD exacerbations, as it shortens recovery time, improves FEV1, and reduces the risk of early relapse and treatment failure 1. DuoNebs provide quick relief by combining a short-acting beta-agonist (albuterol) with an anticholinergic (ipratropium) to open airways rapidly, which is in line with the recommendation for initial bronchodilator treatment in acute exacerbations 1. Trelegy, a maintenance inhaler containing three medications, works to keep airways open and reduce inflammation long-term, and its use is supported by evidence showing improved lung function, symptoms, and health status, as well as reduced exacerbations 1. The Z-pack (azithromycin) addresses potential bacterial infections that often trigger COPD exacerbations, and its use has been shown to reduce the risk of exacerbations in patients prone to them 1.
Key Considerations
- The dose and duration of prednisone should be carefully considered, as systemic glucocorticoids may be less efficacious in patients with lower blood eosinophil levels 1.
- Patients should be monitored for side effects, including increased heart rate, tremors, oral thrush, and stomach upset, and ensure proper inhaler technique for maximum benefit.
- After the acute phase, the prednisone and Z-pack will be completed, while Trelegy should be continued daily for maintenance therapy, and DuoNebs may be reduced to as-needed use once symptoms improve.
Evidence-Based Practice
The treatment regimen is based on the most recent and highest quality evidence, including the 2017 Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease report 1. This evidence supports the use of systemic corticosteroids, bronchodilators, and antibiotics in the treatment of COPD exacerbations, and highlights the importance of maintenance therapy to prevent future exacerbations.
From the Research
Medications for COPD
- Prednisone 40mg daily: The use of prednisone 40mg daily for COPD is supported by studies such as 2, which suggests that low-dose corticosteroid regimens like prednisone 40mg orally once/day for 10-14 days are effective in managing acute exacerbations of COPD.
- Duonebs (ipratropium bromide/albuterol): Studies like 3 and 4 compare the efficacy of ipratropium bromide/albuterol with other treatments, such as fluticasone propionate/salmeterol, and show that while both treatments can improve lung function and symptoms, fluticasone propionate/salmeterol may be more effective.
- Trelegy (fluticasone furoate/umeclidinium/vilanterol): The use of single-inhaler triple therapy like Trelegy is discussed in 5, which summarizes the evidence for its use in COPD and highlights the need for further studies to clarify its optimal use.
- Zpack (azithromycin): There is no direct evidence in the provided studies regarding the use of Zpack for COPD.
Treatment of COPD Exacerbations
- The study 6 supports the use of prednisone 40mg (or equivalent) for 5 days in the treatment of severe acute exacerbations of COPD, and highlights the importance of adhering to evidence-based recommendations to minimize adverse effects and readmissions.
- The use of systemic corticosteroids, such as prednisone, is a standard of care for managing acute exacerbations of COPD, as discussed in 2.