US Pharm. 2013;38(7):43-46.
ABSTRACT: Chronic obstructive pulmonary disease
(COPD) is currently the third leading cause of death in the United
States and is a major cause of disability. The recently updated Global
Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines
address the management of stable COPD. Management of symptoms can
decrease exacerbation risk and limit emergency room and hospital visits.
As part of the multidisciplinary team, pharmacists can be an invaluable
resource in educating patients about the disease and the proper
administration of medications. Pharmacists can also have an active role
in nonpharmacologic treatments such as smoking cessation and vaccine
Chronic obstructive pulmonary disease (COPD) is a very
common disease, with approximately 12 million people diagnosed in the
United States.1,2 COPD has been associated with increased
mortality, and many people remain undiagnosed. It is currently the third
leading cause of death in the U.S. and is a major cause of disability.1
In 2005, more than 3 million people died as a result of COPD. Within
the next 10 years, the total number of deaths from COPD is projected to
increase by more than 30%.3 Previously, men were six times more likely to die from COPD than women; however, new data suggest that this trend has reversed.1
In 1998, a multidisciplinary team of physicians, health
providers, and scientists across the world came together to form the
Global Initiative for Chronic Obstructive Lung Disease (GOLD) to
increase the awareness of COPD. The GOLD committee developed a consensus
report known as the Global Strategy for the Diagnosis, Management, and Prevention of COPD that was last revised in 2011 and most recently updated in February 2013.4 This article will review updates to current guidelines for the management of stable COPD.
COPD is a preventable and progressive disease that is
characterized by an increased chronic inflammatory response resulting in
persistent airflow limitation.5 When exposed to noxious
particles like tobacco smoke, an inflammatory response is initiated to
release neutrophils and macrophages into the lungs and airways. This
results in the release of chemical mediators like tumor necrosis factor
alpha, interleukin 8, and leuko-triene B4. This inflammatory response is comple-mentary and leads to damage to the airways, pulmonary vasculature, and lung parenchyma.2
This state of chronic inflammation causes fibrosis due to constant
repair, resulting in airflow limitation. Other processes like oxidative
stress and imbalances of proteases and antiproteases may also play a
COPD is diagnosed by spirometric results that guide
therapy. In the updated GOLD guidelines, the severity of COPD has become
more multifactorial based on patient symptoms, degree of spirometric
abnormality, exacerbation risk, and presence of comorbidities.4 Physicians should perform individual assessments of patients to determine the classification of disease severity.
It is often recognized that patients with COPD have
multiple comorbidities that can have a major impact on quality of life
and survival. These comorbidities can include cardiovascular disease,
skeletal muscle dysfunction, metabolic syndrome, osteoporosis,
depression, and lung cancer. It is recommended that these be identified
and treated appropriately to reduce the exacerbation risk.4
The exposure to risk factors greatly impacts patients and
their likelihood of developing COPD. Common risk factors include male
gender, age >40 years, low socioeconomic status, occupational dusts,
indoor/outdoor air pollution, respiratory infections, and genetic
predisposition. The most common worldwide risk factor for COPD is
Symptoms commonly associated with COPD include chronic
cough, sputum production, and dyspnea. Frequently, questionnaires are
utilized to assess the severity of individual symptoms. The Modified
British Medical Research Council (mMRC) questionnaire is used to
determine the health status of a patient by assessing physical
limitations due to shortness of breath. The COPD Assessment Test (CAT)
questionnaire is utilized to assess a patient’s quality of life with
COPD. Furthermore, the Clinical COPD Questionnaire (CCQ) measures
clinical control in patients. Current guidelines recommend the mMRC or
CAT questionnaire as a tool to assess symptoms.4
In order to clinically diagnose COPD, spirometry is
required after administration of a short-acting inhaled bronchodilator.
An FEV1/FVC ratio (forced expiratory volume in 1 second/forced vital capacity) of <0.70 confirms airflow limitation.4 TABLE 1 shows the classification of airflow limitation and its correlation to disease severity, commonly referred to as COPD stage.4
There are few data to suggest that spirometric evaluation alone will
adequately assess the health status of the patient. It is recommended
that spirometry be used in combination with assessment of symptoms and
An exacerbation is defined as an acute event that
is associated with worsening of any symptom (cough, sputum production,
or dyspnea) beyond normal day-to-day functioning. COPD exacerbations can
result in visits to the physician’s office, emergency room, and/or
hospital. Frequent exacerbations have a high correlation with increased
hospitalizations and an increased risk of mortality. Patients can be
deemed to have a high exacerbation risk if they are categorized as GOLD 3
or 4 or if they have a history of two or more exacerbations in the past
From the latest GOLD updates, it is now recommended to
classify patients into groups (A, B, C, or D) based on the criteria seen
in FIGURE 1.4 Utilize the example in the following paragraph to determine how to use this chart.
A 55-year-old patient presents with an mMRC score of 2 and a CAT score of 12. Spirometry readings showed an FEV1
of 70% of predicted and four COPD exacerbations within the past year.
When assessing a patient, start with determining his or her symptoms as
represented by the CAT and/or mMRC questionnaires. In this example, the
patient would be classified as either Group B or D because the
questionnaire results correlate with more symptoms. Next, look at the
patient’s risk by comparing spirometry readings and exacerbation
history. When the spirometry results are evaluated, the patient would be
described as moderate disease (GOLD 2), which correlates with low risk,
or Group B. When the patient’s exacerbation history is looked at, he or
she would be classified as high risk, or Group D. It is recommended
that the highest risk parameter be utilized to yield a more
accurate reflection of the patient’s current COPD status. Therefore,
this patient would be classified as Group D based on the high severity
of risk associated with the history of exacerbations.
Treatment Options for Stable COPD
COPD is a progressive disease that worsens with time, and
available treatment options will not eradicate the disease. Treatment
goals include reducing current symptoms and future exacerbation risk.4
Effective management depends on the patient’s past medical history,
current symptoms, tolerance to therapy, and accessibility to
medications. Each patient should be educated about the disease state,
decreasing exposure to common risk factors, proper inhaler technique,
and exacerbation risk. Studies have shown that patients who are more
knowledgeable about their disease are more likely to have increased
medication adherence.6 Pharmacists are in the optimal setting to provide this fundamental education.
Nonpharmacologic Treatment Options
Smoking Cessation: Regardless of COPD severity, smoking cessation is considered the most important intervention for individuals who smoke.4
Pharmacists play an integral role in assisting patients in identifying
nicotine replacement therapy options (e.g., nicotine inhalers, nasal
sprays, OTC nicotine gum, transdermal patches, lozenges, or electronic
cigarettes) to meet their specific needs and in providing counseling on
appropriate usage. Additionally, health professionals, including
pharmacists who provide smoking cessation counseling, have been shown to
increase quit rates among patients compared to self-initiated attempts.7
Pulmonary Rehabilitation: Health care
providers offer a variety of services to patients including exercise
and strength training, nutrition counseling, and breathing techniques to
improve the level of physical activity. It has been shown that patients
who are able to maintain physical activity develop an increased
exercise tolerance and are less likely to experience dyspnea and
fatigue. Exercise training has also been shown to decrease the risk of
Immunizations: Since they are at an
increased risk of lower respiratory tract infections, patients with COPD
should receive the pneumococcal and annual influenza vaccinations. It
has been shown that patients with COPD who have received both
vaccinations are at a decreased risk of acquiring pneumonia or influenza
compared to patients who are not vaccinated.9 The role of
pharmacists in providing services like immunizations has expanded
significantly. Depending on state laws, these vaccinations can be
offered conveniently in many community pharmacy settings.
Pharmacologic Treatment Options
Current treatment options aid in improving symptoms and
decreasing the risk of exacerbations. Pharmacologic agents are selected
depending on the patient’s individual response, tolerability, and
availability. TABLE 2 lists drugs commonly used in the treatment of COPD and their adverse effects.4,10
Treatment is not solely dependent on a patient’s
spirometry readings. The GOLD guidelines provide a stepwise approach for
treatment recommendations based on COPD patient staging (TABLE 3).4 Available treatment options can be categorized as bronchodilators or anti-inflammatory agents.
Bronchodilator Therapy: Bronchodilators
are the mainstay of treatment for COPD; they include short- or
long-acting anticholinergics (SAMAs or LAMAs) and short- or long-acting
beta2 agonists (SABAs or LABAs). Beta2 agonists relax smooth muscle in the airways by stimulating beta2 receptors to increase production of cyclic adenosine monophosphate (cAMP) to promote bronchodilation.10 LABAs and anticholinergics (muscarinic antagonists) are preferred over short-acting formulations.4
Depending on disease severity and patient symptoms, medications may be
utilized daily or as needed. Long-acting inhaled bronchodilators reduce
the number of exacerbations and related hospitalizations. Most of the
treatment options for COPD can be used in combination therapy. If
symptoms persist, it is plausible to combine SABAs and LABAs with
anticholinergics if symptoms are not controlled by monotherapy.
In 2002, it was estimated that the economic burden of COPD was $32.1 billion.11
A study showed that when treatment followed GOLD guidelines using a
combination therapy of a LABA, a long-acting anticholinergic, or inhaled
corticosteroids (ICS) to treat moderate-to-severe disease, the cost of
COPD management decreased.11 Methylxanthines like
theophylline are not recommended due to their adverse-effect profile and
narrow therapeutic index, unless bronchodilators are not available or
affordable for the patient.
Many patients with COPD also have a concurrent diagnosis
of asthma. LABA monotherapy in COPD has not been found to increase
respiratory mortality. While there are no restrictions on LABA use in
COPD, there is controversy with LABAs as sole therapy for asthma, since
concerns have been raised suggesting that its use could lead to an
increased risk of respiratory death in asthma patients.12 Based on these findings, it is not recommended to manage patients with COPD and asthma with LABAs alone.
Every patient should ensure that they have quick and easy
access to short-acting bronchodilators at all times. These agents have
the quickest onset of action and work to improve respiratory symptoms
within 15 minutes. Side effects may include increased heart rate, throat
irritation, or cough.10 Caution should be advised with
regard to storing the medication in a vehicle, especially during warmer
months, as some canisters may be pressurized.
Anti-inflammatory Therapy: ICS are
used in combination with a long-acting bronchodilator in the management
of COPD. There is controversy about the efficacy of ICS in the treatment
of COPD, because it is thought that the chronic inflammation is not
reversible as compared to asthma. Additionally, the use of ICS has been
associated with adverse effects including an increased risk of pneumonia
in elderly patients with COPD.13 Oral corticosteroids are often prescribed for COPD exacerbations to shorten recovery time, improve lung function (FEV1) and arterial hypoxemia (PaO2), and reduce the length of hospital stay, the risk of early relapse, and the risk of treatment failure.4
The typical duration of systemic corticosteroid use for acute COPD
exacerbations ranges from 10 to 14 days, but new studies have shown that
5 days of treatment may be noninferior to the standard length of
therapy.14 Corticosteroids are associated with adverse
effects such as glucose intolerance (hyperglycemia), fluid retention,
and increased appetite.10
Roflumilast, a phosphodiesterase-4 (PDE4) inhibitor, is an
oral medication that inhibits the breakdown of intracellular cAMP to
suppress inflammatory activity.10 Roflumilast may be used to decrease exacerbations in patients with chronic bronchitis and severe/very severe COPD.15
It is indicated as adjunct therapy to a long-acting bronchodilator. A
medication guide is required to be dispensed with the prescription due
to its potential adverse effects including mood disturbances, weight
loss, and suicidal ideation.15
Conclusion and Role of the Pharmacist
There are a variety of treatment options available for
COPD based on the clinical judgment of the provider to improve symptoms
and daily quality of life for each patient. Pharmacists play an
important role in educating patients about common adverse effects
associated with medication therapy, as well as in providing smoking
cessation counseling and vaccine administration. Furthermore,
pharmacists can render assistance on proper inhaler technique to promote
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