The goal of COPD management is to improve a patient’s functional status and quality of life by preserving optimal lung function, improving symptoms, and preventing the recurrence of exacerbations. Currently, no treatments aside from lung transplantation have been shown to significantly improve lung function or decrease mortality. Once the diagnosis of COPD is established, it is important to educate the patient about the disease and to encourage his or her active participation in therapy.
Results of a randomized controlled trial showed that a comprehensive disease management strategy, which included a patient education session, a self-treatment plan for exacerbations, and a monthly follow-up call from a case manager, is associated with a lower hospitalization rate and fewer emergency department visits.[43] A study by Dewan et al determined that a multicomponent disease management program in patients with COPD was cost-effective, saving $593 per patient.[44]
Indications for intensive care admission are confusion, lethargy, respiratory muscle fatigue, worsening hypoxemia, and respiratory acidosis (pH < 7.30), as well as clinical concern for impending or active respiratory failure. (BiPAP can be done on the floor in some hospitals, including widely in the United Kingdom).
Oral and inhaled medications are used for patients with stable disease to reduce dyspnea and improve exercise tolerance. Most of the medications used are directed at the following 4 potentially reversible causes of airflow limitation in a disease state that has largely fixed obstruction:
Bronchial smooth muscle contraction
Bronchial mucosal congestion and edema
Airway inflammation
Increased airway secretions
Diet
Inadequate nutritional status associated with low body weight in patients with COPD is associated with impaired pulmonary status, reduced diaphragmatic mass, lower exercise capacity, and higher mortality rates. Nutritional support is an important part of comprehensive care in patients with COPD.
Bronchodilation
Bronchodilators are the backbone of any COPD treatment regimen. They work by dilating airways, thereby decreasing airflow resistance. This increases airflow and decreases dynamic hyperinflation. Lack of response in pulmonary function testing should not preclude their use. These drugs provide symptomatic relief but do not alter disease progression or decrease mortality.
Beta2 agonists and anticholinergics
The initial choice of agent remains in debate. Historically, beta2 agonists were considered first line and anticholinergics were added as adjuncts. Not surprisingly, studies have shown combination therapy results in greater bronchodilator response and provides greater relief. Monotherapy with either agent and combination therapy with both are acceptable options. The adverse effect profile may help guide therapy. Generally, long-acting bronchodilators are more beneficial than short-acting ones.[2, 11, 16]
Beta2-agonist bronchodilators activate specific B2-adrenergic receptors on the surface of smooth muscle cells, which increases intracellular cyclic adenosine monophosphate (cAMP) and smooth muscle relaxation. Even patients who have no measurable increase in post-bronchodilator expiratory airflow may benefit from treatment with beta2 agonists. The inhaled route is preferred because it minimizes adverse systemic effects. The adverse effects are predictable and include tachycardia and tremors. Although rare, beta2 agonists may also precipitate a cardiac arrhythmia.
Anticholinergic drugs compete with acetylcholine for postganglionic muscarinic receptors, thereby inhibiting cholinergically mediated bronchomotor tone, resulting in bronchodilation. They block vagally mediated reflex arcs that cause bronchoconstriction. Clinical benefit is gained through a decrease in exercise-induced dynamic hyperinflation. These agents are poorly absorbed systemically and are relatively safe. Reported adverse effects include dry mouth, dry eyes, metallic taste, and prostatic symptoms.
In a study of men with COPD aged 66 years or older from Ontario, Canada, acute urinary retention (AUR) was found to be significantly more prevalent in users of inhaled anticholinergic medications (IACs) than in nonusers. The risk of AUR was higher in patients receiving both short-acting and long-acting IACs than in patients using a single IAC, and evidence of benign prostatic hyperplasia also increased the AUR risk.[45]
Inhaled delivery of medications is preferred over the oral route to help minimize potential adverse effects. Some patients may have difficulty achieving effective delivery of the medication using a metered-dose inhaler; use of a spacer or nebulizer may be beneficial in these patients.
The use of newly prescribed inhaled long-acting beta-agonist and long-acting anticholinergic drugs for COPD was associated with a 31% increased risk of experiencing a cardiovascular event in a recent nested case-control analysis of a retrospective cohort study. Both agents showed an increased risk of acute coronary syndrome and heart failure, but not arrhythmias or stroke. With both agents, the risk of events was highest within the first 2 or 3 weeks of initiating treatment. There was no significant difference in events between the 2 treatments.[46, 47]
In 2013, the results from the SPARK trial showed that in patients with severe COPD, a once-daily fixed-dose combination of indacaterol (a beta2 agonist) and glycopyrronium (a muscarinic antagonist) can improve lung functioning and reduce exacerbations, as compared with monotherapy with either glycopyrronium or tiotropium (both of which are muscarinic antagonists).[48]
Also in 2013, indacaterol and tiotropium were shown to be equally effective in a 52-week, randomized, blinded, parallel-group study consisting of more than 3400 patients with severe COPD who had had at least one exacerbation in the past year.[49, 50] Results from use of the 2 agents demonstrated similar improvements in baseline dyspnea and health status, with similar safety profiles.
Patients treated with indacaterol had a 29% higher exacerbation rate, but needed rescue medication less frequently than patients treated with tiotropium.[49, 50] In both groups, improvements were observed from baseline in trough FEV1 at week 12 (0.114 L with indacaterol and 0.126 L with tiotropium) and at week 52 (0.073 L with indacaterol and 0.092 L with tiotropium).[49, 50]
In 2015, glycopyrrolate was approved as a new respiratory inhalant dosage form. Glycopyrrolate is a long-acting muscarinic antagonist (LAMA) that produces bronchodilation by inhibiting acetylcholine’s effect on muscarinic receptors in the airway smooth muscle. It is available alone (Seebri Neohaler) and in combination with indacaterol, a long-acting beta2-agonist (Utibron Neohaler).
Approval of indacaterol/glycopyrrolate inhaler was based the FLIGHT1 and FLIGHT2 12-week trials (n=2038) that measured lung function compared with its individual bronchodilator components, as well as placebo. Indacaterol/glycopyrrolate was statistically superior in terms of FEV1 area under the curve from 0-12 hours compared with its individual components (P <.001). Statistically and clinically meaningful improvements in St. George's Respiratory Questionnaire total score, transition dyspnea index total score, and reduction in rescue medication use were observed with indacaterol/glycopyrrolate compared with placebo (P <.001).[51]
Glycopyrrolate inhaled/formoterol (Bevespi Aerosphere) is a long-acting muscarinic antagonist (LAMA)/long-acting beta2-agonist (LABA) combination that was approved in April 2016. It is indicated for the long-term, maintenance treatment of airflow obstruction with COPD, including chronic bronchitis and/or emphysema. Approval is based on the PINNACLE trial program, which demonstrated that the glycopyrrolate/formoterol combination inhalant achieved statistically significant improvement in morning predose FEV1 at 24 weeks (P <.001) compared with the individual components of the combination and placebo.[52]
Umeclidinium bromide and vilanterol (Anoro Ellipta) is a LAMA and LABA inhalation powder approved by the FDA for long-term maintenance of COPD.[53, 54]Approval was based on a series of dose-ranging studies in more than 2400 patients—two 6-month, placebo-controlled efficacy and safety studies; two 6-month, active-controlled efficacy and safety studies; and a 12-month safety study.[54, 55] This agent carries a boxed warning regarding use of LABAs and an increased risk of asthma-related death.[53, 54] Umeclidinium and vilanterol inhalation powder is not approved for asthma therapy, and it is not meant to be used as rescue therapy for sudden breathing problems (eg, acute bronchospasm). Serious adverse effects include paradoxical bronchospasm, cardiovascular effects, acute narrow-angle glaucoma, and worsening of urinary retention.[53, 54]
Olodaterol inhaled (Stirverdi Respimat) was approved by the FDA in July, 2014, for maintenance bronchodilator treatment in patients with COPD. Olodaterol is a long-acting beta2 agonist (LABA) that activates specific β2-adrenergic receptors on the surface of smooth muscle cells, which increases intracellular cAMP and smooth muscle relaxation. Approval was based on data from more than 3,000 patients with COPD studied over a 48-week period. Results demonstrated the long-term efficacy (eg, improved FEV1 at 0-3 hr and trough FEV1) and safety of once-daily olodaterol 5 mcg in patients with moderate to very severe COPD continuing with usual-care maintenance therapy.[56, 57]
Tiotropium
Although the results of the Understanding Potential Long Term Impacts on Function With Tiotropium (UPLIFT) trial did not show a change in the rate of decline of FEV1 or mortality when compared with placebo, it did show a significant reduction in the frequency of COPD exacerbations and hospitalizations and an improvement in quality of life.[58, 59, 60, 61]
Evidence is mounting of the efficacy of tiotropium over long-acting beta agonists. Two large, randomized trials have compared tiotropium, salmeterol (Serevent), and placebo.[59, 62] Both studies showed greater improvement in lung function, dyspnea, and quality of life in the tiotropium group versus the salmeterol group. A study by Brusasco et al also showed a delay in first exacerbations and fewer exacerbations per year in the tiotropium group.[62]
A 1-year, randomized, double-blind, double-dummy, parallel group study by Vogelmeier et al determined that tiotropium is more effective than salmeterol in preventing exacerbations in patients with moderate-to-very-severe COPD.[63]
Tiotropium is available in a capsule dosage form containing a dry powder for oral inhalation via the HandiHaler inhalation device. For adults, the contents of 1 capsule (18 mcg) are inhaled every day via the HandiHaler device. Contraindications, drug interactions, and adverse effects are similar to those of ipratropium.
A systematic review and meta-analysis by Singh et al of 5 randomized controlled trials of the Respimat tiotropium mist inhaler in patients with COPD found a 52% increased risk of mortality (all cause) versus placebo.[64] A randomized study comparing the Respimat mist inhaler to the HandiHaler inhalation device is ongoing as of August 2011.
Aclidinium
Aclidinium (Tudorza Pressair), a long-acting, antimuscarinic (M3) metered-dose inhaler was approved by the FDA in July 2012. Approval was based on randomized, placebo-controlled, clinical trials involving 1276 patients aged >40 years with COPD. The mean 12-week predose FEV1 improvements vs placebo were 0.12 L, 0.07 L, and 0.11 L (P< 0.001) in the trials, with a 24-week improvement of 0.13 L in the 6-month trial. Mean peak improvements in lung function (FEV1) assessed after the first dose were similar to those observed at week 12 in each study.[65]
Umeclidinium bromide
Umeclidinium bromide blocks the action of acetylcholine at muscarinic receptors in the bronchial airways (M3) by preventing increase in intracellular calcium concentration, leading to relaxation of airway smooth muscle. It is available in the United States as a combination inhaled powder with vilanterol (Anoro Ellipta), and is the first once-daily dual bronchodilator approved. It is also available as a single entity inhaler (Incruse Ellipta). Approval for the combination was based on 7 phase III trials including nearly 6,000 patients with COPD. Four 24-week primary efficacy studies (measuring improvement of trough FEV1) and a 52-week long-term safety study were the key studies. Two 12-week exercise/lung function studies provided supportive lung function data and contributed to safety data.[66, 67]
Phosphodiesterase inhibitors
Phosphodiesterase inhibitors increase intracellular cyclic adenosine monophosphate (cAMP) and result in bronchodilation. Additionally, they may improve diaphragm muscle contractility and stimulate the respiratory center.
Theophylline is a nonspecific phosphodiesterase inhibitor and is now limited to use as an adjunctive agent. Theophylline has a narrow therapeutic window with significant adverse effects, including anxiety, tremors, insomnia, nausea, cardiac arrhythmia (particularly multifocal atrial tachycardia), and seizures. It is reserved for patients with hard-to-control COPD or for individuals who are not able to use inhaled agents effectively.
Theophylline is metabolized primarily via the hepatic cytochrome P450 system, a process affected by age, cardiac status, and liver abnormalities. Serum levels of theophylline need to be monitored because of the potential for toxicity. The previously recommended target range of 15-20 mg/dL has now been reduced to 8-13 mg/dL.
Roflumilast (Daliresp) and cilomilast (Ariflo) are second-generation, selective phosphodiesterase-4 inhibitors. They cause a reduction of the inflammatory process (macrophages and CD8+ lymphocytes) in patients with COPD. Cilomilast is completely absorbed following oral administration and has a half-life of approximately 6.5 hours. A dose of 15 mg twice daily has been found to be clinically effective. Nausea, presumably of central origin, is the principal adverse reaction. The FDA advisory panel rejected approval of cilomilast in 2002.
Roflumilast was approved by the FDA in 2011 as a treatment to reduce the risk of COPD exacerbations in patients with severe COPD associated with chronic bronchitis and a history of exacerbations. In 2 randomized, double-blind, placebo-controlled, multicenter trials, increased FEV1 levels were found in patients who received roflumilast, and the rate of COPD exacerbations was reduced by 17% in these patients.[68]
Endogenous opioids
A study by Gifford et al found that the administration of endogenous opioids modulated the intensity and unpleasantness of breathlessness in patients with COPD.[69]
Beta-adrenergic antagonists (beta-blockers)
Cardiovascular disease is common in patients with COPD and is a leading cause of mortality; however, use of beta-blockers has been discouraged in these patients due to a perceived risk of bronchospasm and concern about inhibition of beta-agonist medication. However, a study by Short et al of 5977 patients in Scotland found that the addition of a cardioselective beta-blocker to established inhaled treatment did not appear to harm pulmonary function and did reduce COPD exacerbations, hospital admissions, and all cause mortality versus controls
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