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COPD Treatments

PBL : Some People Who Smoke are Unlucky


Sarah Khan
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Bronchodilators, Steroids, Diuretics

COPD is an obstructive lung disease.

Bronchodilators (-adrenergic agonists, anticholinergics, and


methylxanthines)

Steroids (Inhaled, occasionally systemic)

Diuretics (edema, CHF)


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Bronchodilators
Bronchodilators are a mainstay of COPD treatment.

Effective in alleviating symptoms and improving exercise


capacity, and they can produce significant increases in FEV1

Effect through smooth-muscle relaxation improved lung


emptying, reduced thoracic gas volume and residual volume,
and lessened dynamic hyperinflation.

Oral theophylline has been shown to lessen dyspnea and


improve the health-related quality of life despite lack of
significant rise in FEV1, with improvements believed to be a
result of increased respiratory muscle performance.*

*Beware! narrow therapeutic index of older methylxanthines


(which are phosphodiesterase inhibitors) and their potential for
adverse drug-drug interactions have hindered their widespread
use.
+ Corticosteroids
Inhaled corticosteroids play an important role in managing patients with
stable COPD. Systemic steroids should generally be reserved for managing
acute exacerbations.

The weight of evidence from randomized, placebo-controlled trials of


inhaled corticosteroids in patients with COPD shows no effect on the rate of
FEV1 decline,35,59-62 although one study (TORCH) did show a slowed rate
of FEV1 decline in patients who received inhaled steroids.

The combination of inhaled fluticasone and salmeterol appears better than


placebo in enhancing health-related quality of life and lessening
exacerbation frequency. The one trial (TORCH) that examined mortality as a
primary outcome measure showed that the combination of inhaled
fluticasone and salmeterol (500 mcg/50 mcg, respectively, twice daily)
conferred a 2.6% absolute reduction in mortality (15.2%-12.6%; 17.5%
relative reduction), although this difference missed statistical significance (P
= 0.052).

Currently, inhaled corticosteroids are widely used, especially for patients


with frequent exacerbations of COPD, although recent concerns about
excess pneumonia risk in users of inhaled steroids have spurred some
controversy and will certainly receive prospective scrutiny.
+ A 70-year-old smoker with a 50 pack-year smoking history is
currently using a daily disk inhaler that delivers salmeterol and
fluticasone.

In addition, she has been recently discharged from the hospital


for a chronic obstructive pulmonary disease (COPD)
exacerbation and is being tapered off her 2-week course of oral
prednisone. At one point, theophylline was added to her
regimen during the inpatient stay and she was sent home with a
prescription for supplemental oxygen to be delivered for 12
hours during the night. Which of the agents that this patient is
currently taking has been shown to decrease overall mortality in
patients with COPD?

(A) Inhaled glucocorticoids

(B) Salmeterol

(C) Supplemental oxygen

(D) Theophylline
The correct answer is C. Supplemental oxygen is the only
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therapy demonstrated to decrease mortality in patients with
chronic obstructive pulmonary disease. For patients with resting
hypoxemia (resting arterial oxygen saturation < 88%, or < 90%
with signs of pulmonary hypertension or right heart failure), the
use of oxygen has been demonstrated to have a significant
impact on mortality. The Medical Research Council Trial
demonstrated that 12 hours per day was superior to no oxygen
supplementation, but continuous oxygen was even better.

Answer A is incorrect. Several recent trials have failed to find a


beneficial effect for the regular use of inhaled glucocorticoids
on the rate of decline of lung function, as assessed by forced
expiratory volume in 1 second.

Answer B is incorrect. Although chronic obstructive pulmonary


disease (COPD) is characterized by airway
inflammation/obstruction that is largely irreversible, salmeterol
given in the acute setting can be used to improve any
component of airway constriction that is reversible. No studies
have shown that it affects overall mortality in COPD.

Answer D is incorrect. Theophylline has not be shown to


decrease mortality in chronic obstructive pulmonary disease.
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What therapies have been shown
to improve mortality in COPD?
Among the available therapies for COPD, many can improve
symptoms (i.e., bronchodilators, pulmonary rehabilitation).

However, only THREE treatments have been shown to


prolong life in appropriately selected COPD patients.

smoking cessation

supplemental oxygen used 24 hours a day

lung volume reduction surgery

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