Treatment for Chronic Obstructive Pulmonary Disease

Commonly known as emphysema, chronic obstructive pulmonary disease (COPD) affects an estimated 24 million Americans, only half of whom are diagnosed. This article presents recent information regarding the use of drug treatments, including inhaled anti-inflammatory steroids, as well as important nondrug treatments that can be used as an adjunct to drug therapy.

What is COPD?

COPD is a chronic, progressive lung disease characterized by decreased airflow. It is caused by destruction of the small air sacs (alveoli) and loss of elasticity of the small airways, resulting in those airways collapsing when the patient exhales. In turn, the increasing obstruction of airflow when breathing out results in shortness of breath.

The most common cause of COPD is smoking. Other contributing factors include occupational exposures, air pollution and infections. Currently, COPD is the fourth leading cause of death in this country and is projected to be the third leading cause by 2020.

Smoking cessation is the most effective way to prevent COPD or to slow its progression and improve survival for those afflicted. Because people with COPD often have a more serious case of flu or pneumonia than those with normal lungs, they also are urged to get both an influenza vaccine (annually) and a pneumococcal vaccine (at least once).

Determining drug treatment

The degree to which drug treatment is recommended for stable COPD depends on the severity of disease, as determined by breathing tests measuring the level of impairment in exhaling. The three levels of impairment, which correspond with the amount of obstruction in the lungs, are mild, moderate and severe. The table illustrates the different treatments for each level of severity.

Bronchodilators, which relax the bronchial muscles, are a common treatment available in short-acting and long-acting varieties.

There are two types of short-acting bronchodilators, available as metered-dose inhalers and nebulizers: short-acting beta-agonists (SABAs) and short-acting anticholinergics.

SABAs treat and relieve shortness of breath when necessary. Called “rescue inhalers,” SABAs are recommended for certain uses, including mild COPD, but they also can be used as regular (maintenance) therapy for moderate or severe COPD. SABAs work by promptly relaxing the tight muscles surrounding the small airways. Examples include albuterol, levalbuterol and pirbuterol.

Short-acting anticholinergics should be used only as needed if symptoms are both mild and occur infrequently. But for symptoms that are more severe or frequent, they can be used on a regular basis. An example of this kind of drug is ipratropium (ATROVENT).

As indicated in the table, moderate or severe COPD can sometimes be improved by using a combination of short-acting bronchodilators from each of these two classes.

Long-acting bronchodilators are used for the treatment of moderate to severe COPD and also are available in two varieties, formulated as either dry powder inhalers or nebulizers. Like SABAs, long-acting beta-agonists (LABAs) relieve shortness of breath but have much longer duration. Examples of these drugs include salmeterol (SEREVENT), formoterol (FORADIL) and indacaterol (ARCAPTA). Public Citizen has categorized the recently approved indacaterol as Do Not Use because in addition to pre-approval questions about its safety and efficacy, it is a newly approved drug with no unique clinical benefits. (See “The Seven-Year Rule for Safer Prescribing” from the October 2012 issue of Worst Pills, Best Pills News, on the dangers of prescribing nonunique new drugs.)

Long-acting anticholinergics can also reduce the risk of acute COPD attacks, sometimes called flares. An example of this kind of drug is tiotropium (SPIRIVA).

Table: Regular Maintenance Treatment and As-Needed Symptom Relief Treatment for COPD

*Bronchodilators include either beta-agonists or anticholinergics

Inhaled corticosteroids

Inhaled corticosteroids (ICS) are frequently recommended for treatment of persistent asthma, but the efficacy of these drugs is much less well-established for COPD, and their role in COPD treatment is therefore limited. Although there is some controversy about the use of ICS for treatment of COPD in combination with other drugs, it is generally agreed that ICS should rarely, if ever, be used alone (as monotherapy) for the disease. There is very little evidence that ICS can prevent exacerbations in COPD patients, and there is no evidence of benefit, compared to bronchodilator therapy alone, on either mortality or lung-function decline. Adding ICS to regular treatment with a long-acting bronchodilator or to a combination of two short-acting bronchodilators may reduce the number of exacerbations or flares that can characterize severe COPD.

Treatment guidelines therefore recommend the use of ICS only in those patients with severe or very severe disease, especially for those with frequent exacerbations. There is also concern about the increased additional risk of pneumonia with ICS in a number of studies comparing a LABA plus ICS with a LABA alone.

Nondrug approaches

In addition to smoking cessation, pulmonary rehabilitation therapy presents great utility as an adjunct to drug therapy. Its components include a combination of education, exercise training, behavior modification and nutritional counseling. For an initial one to two months, patients may require training sessions of around 30 minutes, several times a week, to learn how to make exercise a regular part of their lives. The overall goals of pulmonary rehabilitation are to improve exercise tolerance and reduce fatigue while improving quality of life by increasing the ability to participate in daily activities.

For patients with very severe COPD, oxygen therapy can make an enormous difference in quality of life. Supplemental oxygen remains the only therapy that has been clearly shown to increase life expectancy in patients with severe COPD.

If You Use ICS

If you use a medicated inhaler for COPD or asthma, you must learn its proper use. Poor technique can render an inhaler ineffective and, for ICS inhalers, increase the risk of such side effects as hoarseness, sore throat and oral thrush. To reduce these side effects, it also is very important to always rinse and gargle with water or mouthwash (“swish and spit”) after using your ICS inhaler.

For a checklist on how to use an inhaler device correctly, visit http://www.nationalasthma.org.au/uploads/content/237-Inhaler_technique_in_adults_with_asthma_or_COPD.pdf.

ICS can increase the risk of pneumonia, so if you develop a fever or productive cough with colored (usually green) phlegm, report these symptoms immediately to your doctor. Also tell your doctor if you experience skin bruising or fragile, thin skin.