Therapeutics of COPD (10-12)

Which is more effective, well-tolerated due to local application, and low systemic absorption, and more expensive….inhaled or oral treatments

inhaled

There is comparable effectiveness and safety within drug classes of COPD treatments, ___ to ____, but notable differences between classes ___ vs. ___ vs. ___ )

LAMA, LAMA

LAMA, LABA, ICS

MOA of Ipratropium

blocks all muscarinic receptors with equal affinity;

Result: inhibits the action of acetylcholine and inhibits bronchoconstriction

What are the side effects of Ipratropium?

Dry mouth

Bitter

Metallic taste

What are some counseling points for Ipratropium?

Rinse mouth to prevent dry mouth and bad taste

Use lowest effective dose

If needing every 4-6 hours, a long-acting bronchodilator is more appropriate

What class is Ipratropium?

SAMA

What are the SABA drugs?

Albuterol

Levalbuterol

What are the MOA of SABA drugs?

Relax bronchial smooth muscle by acting on beta 2 receptors, resulting in bronchodilation

Result: improve FEV1 and dyspnea symptoms

What are the side effects of SABA drugs?

Excitement

Tremor

Tachycardia

Pharyngitis

What are the counseling points of SABA drugs?

Use lowest effective dose

If needing every 4-6 hours arond the clock, a long-acting bronchodilator is more appropriate

Caution in patients with elevated heart rates (a fib)

What are the SAMA/SABA combo drugs?

Ipratropium/Albuterol (Combivent Respimat, DuoNeb)

What are the effectiveness of SAMA/SABA drugs?

Recommended as a combination over either ingredient alone for as needed use

What are the safety and counseling points for SAMA/SABA?

see individual classes for details

What are the LAMA drugs?

Tiotropium

Aclidinium

Umeclidinium

Revenfenacin

What is the MOA of LAMA drugs?

competitive, reversible inhibition of M3 receptors in bronchial smooth muscle

Result: opposition to acetylcholine and bronchodilation of airway smooth muscle

What are the side effects of LAMA drugs?

Dry mouth

Bitter

Metallic taste

No causal link to urinary retention

What are the counseling points for LAMA drugs?

rinse mouth to prevent dry mouth and bad taste

Daily use with consistent timing is important for maximum benefit.

All LAMAs either do not or very minimally cross the blood brain barrier, but not a major concern

What are the LABA drugs?

Salmeterol

Olodaterol

Vilanterol

Arformoterol

Formoterol

What is the MOA for LABA drugs?

relaxes bronchial smooth muscle by acting on beta 2 receptors

Result: bronchodilation of smooth muscle

What are the side effects of LABA drugs?

Nasopharyngitis

cough

mild tremor

possible minor effect on heart rate

What are the counseling points for LABA drugs?

Daily use with consistent timing is important

These are stimulating agents that dilate the airway but narrow blood vessels and increase heart rate

What are the ICS drugs?

Fluticasone Furoate

Fluticasone Propionate

Budesonide

Mometasone

What is the MOA of ICS drugs?

Agents with anti-inflammatory, immunosuppressive properties

Result: reduce airway inflammation and mitigate resultant damage

What are the side effects of ICS drugs?

thrush

hoarse voice

pneumonia

What are counseling points for ICS drugs?

Rinse mouth after use to prevent thrush

Use a spacer with MDI devices to improve absorption

What is the British Modified Medical Research Council Scale (mMRC)?

Scale that focuses on breathlessness and places a patient into a discrete category that describes their degree of breathlessness. (0, 1, 2, 3, 4)

What is the Chronic Airways Assessment Test (CAAT)?

The scale FKA the COPD Assessment Test (CAT)

Scale that covers 8 symptomatic features of COPD (cough, mucus production, chest tightness, breathlessness, limitations to activities)

More comprehensive, but longer to complete

0-5, highest score is 40

When considering initial treatment, what group and what would your prescribe for an exacerbation history of “one or more per year, moderate or severe exacerbations in the previous year”?

Group E

LABA + LAMA

(consider LABA + LAMA + ICS if blood eos >/300)

When considering initial treatment, what group and what would you prescribe for an exacerbation history of “zero, moderate or severe exacerbation in the previous year” ?

Group A - bronchodilator (mMRC 0-1, CAAT < 10)

Group B - LABA + LAMA (mMRC >/2, CAAT >/10)

What classifies patients under each group A, B, and E?

X-axis- know that an mMRC score of 2 or higher and a CAAT score of 10 or greater will more a patient category into the right column. If there is a split between the two scores, you will select the right column (higher of the two scores)

Y-axis - know that the past 1 year is the period of focus for these exacerbations and that a history of 1 moderate or severe exacerbation will decide if someone is designated into E or A/B

Which treatment is preferred for each group?

Be able to classify a patient based on CAAT and/or mMRC score and exacerbation history

Group A is unique in allowing what reserved for patients with infrequent symptoms?

short-acting agents

Both E & B recommend LABA + LAMA, but E recommends triple therapy as initial treatment in patients with an eosinophil count of >/, and is for what?

300 cells/microliter

Exacerbation

What pathway do we use if symptoms are predominating in the absence of exacerbation?

Dyspnea

What pathway (s) do you use if the patient is highly symptomatic and has experienced an exacerbation?

Exacerbation

What pathway do you use if the patient complains of no symptoms but has had an exacerbation?

Exacerbation

What is the dyspnea pathway?

Monotherapy (LABA or LAMA) if persists, needs dual therapy (LABA + LAMA)

What is the Exacerbation pathway?

1) Monotherapy (LABA or LAMA)

if blood eos < 300 → dual therapy

if blood eos >/ 300 → triple therapy

2) If prescribed dual therapy, blood eso <100 → alternative treatment

3) if prescribed dual therapy, blood eos >/ 100 → triple therapy

The ABE assessment used at diagnosis DOES NOT factor into what, even though symptoms with the mMRC and CAAT scales and exacerbation are considered)

follow-up treatment

ICS is only utilized in patients with

moderate-severe exacerbations

If a patient with COPD is stable on ICS/LABA, ___

They stay put on it

If a patient with COPD loses control and has a higher symptom burden with no exacerbations on ICS/LABA,

switch to LABA/LAMA

If a patient on COPD loses control and has an exacerbation on ICS/LABA,

switch to triple therapy

What is an exacerbation according to GOLD 2026 guidelines?

an acute event with symptoms worsening over a few days (up to 14 days) and characterized by increased dyspnea and/or cough and sputum that may be accompanied by tachypnea

What percentage of COPD exacerbations can be managed on an outpatient basis?

80%

What should COPD exacerbations be treated with?

SABA (± SAMA), ± systemic steroids and ± antibiotics

What do we reserve systemic steroids for?

Patients with significant exacerbations, including those with more severe presentations, which can involve not experiencing relief with short-acting bronchodilator therapies

When an oral steroid regiment is needed recommend:

prednisone 40 mg by mouth once daily for 5 days (GOLD 2026)

What do we start for hospitalized patients when oral options are not feasible

IV Methylprednisolone

What do we give patients with a COPD exacerbation with 4 cardinal symptoms

-increase in dyspnea

-fever

-increase in sputum volume

-increase/change in sputum color/purulence

Antibiotics

Why are Z-paks not recommended anymore?

Resistance

What is the new recommended dose of Azithromycin for exacerbations?

Azithromycin 250mg or 500mg po tid three times a week (MWF) x 1 year

True or False

Nebulization is more effective than MDI for administration of SABA/SAMA in ECOPD

False

True or False

MDI is equally as effacacious as nebulization, if patient can maintain proper technique

True

Myth or Fact

Parenteral corticosteroids (methylyprednisolone) are more effacacious than oral steroids in the acute treatment of ECOPD

Myth

Myth or Fact

Parenteral corticosteroids offer no additional benefit with respect to treatment failure, relapse or mortality

Fact

True or False

Evidence-based guidelines recommend 7-14 days of oral corticosteroid therapy

True

True or False

Newer literature indicates that shorter courses of oral corticosteroids (5-7 days) are equal to longer courses of corticosteroids (7-14 days) in regard to treatment failure, hospital length of stay, lung function, and time to next COPD exacerbation

True

Myth or Fact

All patients with moderate to severe ECOPD should receive antibiotics

Myth

Myth or Fact

Only patients who present with the three cardinal symptoms (or patients hwo present with change in sputum color + 1 additional symptom), or those requiring mechanical ventilation, should be started on antibiotics

Fact

What are the vaccine recommendations for COPD patients?

Annual COVID vaccine

Annual flu

Pneumococcal (w/ no previous pneumococcal vaccine received): either Prevnar 20 or 21

or

Prevnar 15 followed by Pneumovax at least 1 year later

1 lifetime Tdap dose + booster at least every 10 years (Td or Tdap)

Shingrix series (2 doses, with second dose 2-6 months after first)

RSV - 60 and older + chronic lung disease

Hep B series

Combination SAMA/SABA is available in which dosage forms?

DPI & Nebulizer

GOLD guidelines preferentially recommend which treatment for as needed, quick-acting relief?

Albuterol

T/F Patients prefer the Spiriva Handihaler over the Respimat

False

Which LAMA is the most well studied?

Tiotropium

T/F 2026 GOLD guidelines rank LAMAs in order of preferred use

false

T'/F: 2026 GOLD guidelines rank LABAs in order of preferred use

false

Which of the following is true with regard to ICS treatment in COPD?

ICS use may be restricted with history of recurrent pneumonia

According to this formulary chart, which SABA would be the most affordable for a Blue Cross of Idaho member?

Levalbuterol Neb

A 67 year old man with a recent COPD-related hospitalization and CAAT score of 21 needs his COPD regimen adjusted. How would you approach his follow-up treatment using GOLD recommended assessment tools?

With his high CAT score and exacerbation history, use the exacerbation pathway