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
Short-acting beta 2-adrenergic agonists (or beta-agonists [SABAs]). Beta-agonists are typically used to treat exacerbations. They facilitate bronchodilation by upregulating cyclic adenosine monophosphate, preventing smooth-muscle contraction, and reducing dynamic hyperinflation. The effect of a SABA lasts 4 to 6 hours.
In general, SABAs are not recommended for daily use in stable COPD. However, they can be useful, and appropriate, for treating occasional dyspnea and can confer additional symptom improvement when used occasionally along with a long-acting beta 2-adrenergic agonist (or beta-agonist [LABA]; discussed later).1
Albuterol, a commonly used SABA, is less expensive than, and just as effective as, same-class levalbuterol for decreasing breathlessness associated with acute exacerbations. There is no significant difference between the 2 drugs in regard to the incidence of tachycardia or palpitations in patients with cardiovascular disease.13
Although no significant differences have been observed in outcomes when a nebulizer or an MDI is used to administer a SABA, it’s wise to avoid continuous SABA nebulizer therapy, due to the increased risk of disease transmission through the generation of droplets.1,4 Instead, it’s appropriate to use an MDI regimen of 1 to 3 puffs every hour for 2 to 3 hours, followed by 1 to 3 puffs every 2 to 4 hours thereafter, based on the patient’s response.1,4
Short-acting muscarinic antagonists (SAMAs). Muscarinic antagonists achieve bronchodilation by blocking acetylcholine on muscarinic receptors. We do not specifically recommend SAMAs over SABAs for treating COPD exacerbations in our patients: There is no difference in improvement in FEV1 during an acute exacerbation. Nebulized delivery of a SAMA raises concern for an increase in the risk of acute narrow-angle glaucoma, a risk that can be reduced by using a mask during administration.1,14
Continue to: SABA + SAMA
