Chronic Obstructive Pulmonary Disease Treatment
Medical treatments for COPD include the following:
Bronchodilators and Anti-inflammatory Agents to Treat COPD
Pharmacological treatment involves bronchodilators (beta2 agonists, anticholinergics, and theophylline) and anti-inflammatory drugs (corticosteroids). These are most effective when inhaled. There are several delivery methods for inhaled medications, including metered-dose inhalers, breath-actuated inhalers, dry powder inhalers, and nebulizers.
The beta2 agonists relax the smooth muscle thereby decreasing bronchoconstriction and airflow obstruction. They also improve the ability to clear mucus and the endurance of fatigued respiratory muscles. Beta2 agonists injected under the skin, such as epinephrine (Epipen), can produce serious side effects (e.g., hypertension, arrhythmia, pulmonary edema) and are only used to treat COPD patients in dire situations.
Ipratropium bromide, an anticholinergic, has a greater bronchodilatory effect than beta2 agonists and has fewer side effects (tachycardia [rapid heart rate] and tremors). Ipratropium bromide is generally recommended for COPD patients who experience symptoms daily.
Theophylline is a bronchodilator and an anti-inflammatory agent. Its use is somewhat controversial because there is a narrow range of safe dosage, so it is prescribed strictly on a case-by-case basis. It may be particularly effective in relieving nocturnal symptoms and has been shown to improve diaphragmatic strength. One study showed that patients with severe COPD who discontinued theophylline had a decline in status compared to those left on the drug. However, improvement and drug levels have to be carefully monitored. Numerous drug interactions raise theophylline levels; if the blood level becomes too high, seizures and arrhythmias can occur without warning.
Corticosteroids are often used to treat inflamed airways, but their long term benefit is not clear. Steroids have not been shown to slow lung decline in COPD. They may reduce the number of exacerbations and improve symptoms in some patients, but there is no convincing evidence to support this. Approximately 10%-15% of COPD patients have a measurable response to corticosteroid therapy with an improvement in FEV1; the remainder do not.
Oral corticosteroids are used when the dose requirement is higher than can be delivered by an inhaler or when the patient cannot use an inhaler. Oral or intravenous steroids are used in acute exacerbations of COPD.
It is difficult to wean patients off steroids and many patients are left on inhaled steroids because they do well on them. Corticosteroids are now given, whenever possible, in an inhaled form rather than orally or intravenously. There are many adverse side effects associated with long-term use. Some studies have shown that COPD patients who use a corticosteroid inhaler for 1 year or longer may be at increased risk for developing pneumonia.
In May 2013, the U.S. Food and Drug Administration (FDA) approved fluticasone furoate and vilanterol inhalation powder (Breo Ellipta) to treat COPD and reduce exacerbations in people over the age of 18. This long-term, once-daily medication decreases inflammation in the lungs and relaxes the muscles around the airways to help increase airflow and improve lung function. It is not approved for the treatment of asthma and contains a boxed warning due to an increased risk for asthma-related death.
Breo Ellipta can cause serious side effects - including a risk for pneumonia and bone fractures. Common side effects include nasal inflammation, respiratory tract infection, headache, and mouth infection (oral candidiasis or thrush).
In December of the same year (2013), umeclidinium and vilanterol powder (Anoro Ellipta) was approved by the FDA for once daily, long-term COPD treatment. This medication, which is combination of an inhaled anticholinergic and a long-acting beta2-adrenergic agonist (LABA), helps to relax the muscles around the airways in people with COPD. Studies show that Anoro Ellipta can improve lung function. This drug also carries a boxed warning and is not approved to treat asthma.
Common side effects of Anoro Ellipta include sore throat, sinus infection, lower respiratory infection, constipation, diarrhea, and pain. Serious side effects like airway narrowing or obstruction, heart problems, acute narrow-angle glaucoma, and urinary retention may occur.
Olodaterol (Striverdi Respimat inhalation spray) was approved in July 2014 to treat adults with COPD who are experiencing obstructed airflow. This medication is used once daily for long-term treatment. Like other LABAs, Striverdi Respimat also carries a boxed warning cautioning about asthma-related death risk and should not be used to treat asthma or sudden breathing problems.
The most common side effects associated with olodaterol include the following:
- Back pain
- Infection (e.g., urinary tract infection [UTI], upper respiratory tract infection)
- Joint pain
- Runny nose
Mucolytics to Treat COPD
Mucus retention narrows the airways and increases symptoms of COPD. A lot of effort has been put into developing medications that break up and allow mucus to be cleared more effectively from the airways. Unfortunately, this has met with only very modest success. Three mucolytic medications may benefit some patients: guaifenesin, potassium iodide, and N-acetylcysteine.
Guaifenesin and potassium iodide are taken orally. N-acetylcysteine is commonly taken through a nebulizer. These are tried on a case-by-case basis to see if they improve symptoms. N-acetylcysteine can cause bronchospasm when taken through a nebulizer.
Antibiotics to Treat COPD
Antibiotics are generally used only for acute exacerbations. Patients who experience frequent exacerbations with purulent sputum (a sign of infection) during the year may be placed on a schedule of prophylactic (preventative) treatment with antibiotics the first 10 days of each month. This is done for special cases only.
Oxygen to Treat COPD
Oxygen is the only treatment that has been shown to improve survival. Indications for oxygen therapy include: arterial PaO2 < 55 mm Hg, or an O2 saturation of 88% with arterial PaO2 of 55-59 mm Hg, or an O2 saturation of 89% accompanied by cor pulmonale (right-sided heart failure), or polycythemia (proportion of red blood cells above 56% of blood sample).
A patient who does not qualify for oxygen as described may need oxygen while sleeping or exercising. Oxygen may be used at night only if the PaO2 at night is less than 55 mm Hg or the O2 saturation is less than 88%. If the PaO2 is less than 55 mm Hg or the O2 saturation is less than 88% during exercise, oxygen may be prescribed.
Nasal cannula is the most commonly used oxygen delivery system and is usually attached to an oxygen concentrator (not portable) or an E cylinder (portable). There are several oxygen-conserving devices used with these systems.