COPD inhaler therapy: A path to success
Keys to therapeutic success include choosing the right device and drug regimen, providing rigorous patient education, and reducing environmental exposures.
PRACTICE RECOMMENDATIONS
› Follow guideline advice that (1) in general, short-acting beta-agonists (SABAs) are not for daily use in stable chronic obstructive pulmonary disease (COPD) but (2) agents in this class of drugs might have a role in relieving occasional COPD-associated dyspnea. C
› Prescribe albuterol over levalbuterol when a SABA is indicated because of the lower cost of albuterol, its comparative efficacy, and its lower incidence of tachycardia and palpitations, even in patients with cardiovascular disease. B
› Avoid the use of an inhaled corticosteroid, or consider withdrawing inhaled corticosteroid therapy, in patients with COPD whose blood eosinophil count is < 100 cells/μL or who have repeated bouts of pneumonia or a history of mycobacterial infection. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Patient education is necessary to ensure that drug is delivered to the patient consistently, with the same expectation of effect seen in efficacy studies (which usually provide rigorous inhaler technique training and require demonstration of proficiency).1,2,10 For the busy clinician, a multidisciplinary approach, discussed shortly, can help. Guidelines developed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommend that inhaler technique be reassessed at every visit and when evaluating treatment response.1TABLE 13-9 provides information on each device type, patient requirements for use, proper technique, common errors in use, and tips for optimizing delivery.
Inhaler education and assessment of technique that is provided to patients in collaboration with a clinical pharmacist, nursing staff, and a respiratory therapist can help alleviate the pressure on a time-constrained primary care physician. Furthermore, pharmacist involvement in the COPD management team meaningfully improves inhaler technique and medication adherence.6,7 Intervention by a pharmacist correlates with a significant reduction in number of exacerbations; an increased likelihood that the patient has a COPD care plan and has received the pneumococcal vaccine; and an improvement in the mean health-related quality of life.11,12
In primary care practices that lack robust multidisciplinary resources, we recommend utilizing virtual resources, such as educational videos, to allow face-to-face or virtual education. A free source of such resources is the COPD Foundation,a a not-for-profit organization funded partly by industry.
Short- and long-acting inhaled medications for COPD
Each class of inhaled medication for treating COPD is discussed broadly in the following sections. TABLE 21 provides details about individual drugs, devices available to deliver them, and starting dosages.
Short-acting agents
These drugs are available in MDI, SMI, and nebulizer delivery devices. When portability and equipment burden are important to the patient, we recommend an MDI over a nebulizer; an MDI is as efficacious as a nebulizer in improving forced expiratory volume in 1 second (FEV1) and reducing the length of hospital stay for exacerbations.4
Continue to: SABAs
