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
The most commonly reported adverse effect of a LAMA is dry mouth. Some patients report developing a bitter metallic taste in the mouth.1
ICSs are not recommended as monotherapy in COPD.1 However, an ICS can be combined with a LABA to reduce the risk of exacerbations in patients with severe COPD (NNT = 22, to prevent 1 exacerbation per year).18 However, this combination increases the risk of pneumonia in this population (number needed to harm [NNH] = 36, to cause 1 case of nonfatal pneumonia per year).18
ICSs increase the incidence of oropharyngeal candidiasis and hoarseness. In addition, ICSs increase the risk of pneumonia in some patients with COPD18—in particular, current smokers, patients ≥ 55 years of age, and patients with a history of pneumonia or exacerbations, a body mass index < 25, or severe COPD symptoms.1,18 ICS therapy does reduce the risk of COPD exacerbations in patients with a history of asthma or with eosinophilia > 300 cells/μL and in those who have a history of hospitalization for COPD exacerbations.19,20
The risk of pneumonia is not equal across all ICS agents. Fluticasone increases the risk of pneumonia (NNH = 23, to cause 1 case of pneumonia in a 22-month period).21 Budesonide showed no statistically significant increase in risk of pneumonia.22 However, further studies on the risk of pneumonia with budesonide are needed because those cited in the Cochrane review21 were much smaller trials, compared to trials of fluticasone, and of low-to-moderate quality. Furthermore, evidence is mixed whether ICS monotherapy in COPD worsens mortality during an 18-month study period.21-23
For these reasons, it’s reasonable to (1) exercise caution when considering the addition of an ICS to LABA therapy and (2) limit such a combination to the setting of severe disease (as discussed already).
Continue to: LABA + LAMA
