Medications

From bronchodilators to corticosteroids: understanding COPD medications

There are many different medications available to manage chronic obstructive pulmonary disease (COPD) and its symptoms. COPD treatments are designed to reduce symptoms, make flare-ups less frequent, and help you feel your best.

 

From inhalers to pills, antibiotics to steroids, it may all feel a bit overwhelming at first. Fortunately, the Canadian Thoracic Society has created guidelines based on the outcomes of recent clinical studies and recommendations from lung specialists across Canada. Here’s what to know.

NEW! Updated 2023 guidelines – Pharmacotherapy for COPD patients

Source: Canadian Thoracic Society

 

Since the 2019 Canadian Thoracic Society Guideline, there has been a lot of new research that has shaped the current guidelines.

In 2023, new guidelines have been published. The recommended medications for COPD aim to use proven and effective treatments based on the latest research. This approach considers factors like symptoms, the risk of future flare-ups, and the risk of mortality. If you aren’t sure of your current medications, make sure to as your healthcare team!

Below are the 3 changes made to the guidelines:

For all individuals with COPD, even those with mild symptoms: Use long-acting inhaled bronchodilators regularly. It’s recognized that everyone with COPD, regardless of severity, should also use short-acting bronchodilators when needed.

For individuals with moderate and severe COPD and a low risk of future flare-ups: Use a single inhaled medication containing both LAMA and LABA is now recommended. This has been shown to be better than using LAMA or LABA alone in this situation.

For individuals with moderate and severe COPD who are at a high risk of future flare-ups: Use a single inhaled medication that combines LAMA, LABA, and ICS. This combination has proven benefits, including a significant reduction in mortality.

Using a single inhaler for this triple therapy is preferred over multiple inhalers because it may offer more benefits, improve adherence, and reduce the chance of mistakes in using the inhaler.

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What type of medications?

AECOPDAcute Exacerbation of COPD

Sudden worsening of symptoms in patients with COPD.

 

CATCOPD Assessment Test

Quantifies impact of COPD symptoms on patients’ overall health.

 

FEV1Forced Expiratory Volume in 1 second

Measures how much air a person can exhale during a forced breath in the first second.

 

ICSInhaled Corticosteroids

They are anti-inflammatory medication.

 

LABALong-Acting Beta Agonists

Inhaler that is a long term control medication. Requires regular use.

 

LAMALong-Acting Muscarinic Antagonists

Inhaler that is a long term control medication. Requires regular use.

 

mMRCmodified Medical Research Council

Assess the degree of dyspnea (shortness of breath).

 

prnpro re nata

It’s a medical abbreviation that originates from the Latin phrase pro re nata, meaning “as needed.”

 

SABDShort Acting Bronchodilator

Inhaler that quickly relieves or stops sudden symptoms.

 

Low Risk of AECOPD is ≤1 moderate AECOPD in the last year (moderate AECOPD is an event with prescribed antibiotic and/or oral corticosteroids), and did not require hospital admission / ED visit.

High Risk of AECOPD is ≥2 moderate AECOPD or ≥1 severe exacerbation in the last year (severe AECOPD is an event requiring hospitalization or ED visit).

Inhalers

The mainstay of inhaled medications to treat COPD are bronchodilators, which are made of two kinds of medication: beta-2-agonists and anticholinergics (a.k.a., muscarinic antagonists). Both of these exist in short-acting and long-acting formulations.

Inhaled Corticosteroid medications (ICS) are another class of medications used for people who are at a high risk of flare-ups or also suffer from asthma. Inhaled corticosteroids should be taken in combination with bronchodilators.

Bronchodilators

A bronchodilator dilates (or opens up) the airways of the lungs to make it easier to breathe. By relaxing the muscles around your airways, it improves the passage of air and the movement of mucus. This helps reduce cough and difficulty breathing. Bronchodilators are prescribed in the early stages of COPD and typically become a lifelong therapy unless the person receives a lung transplant and no longer has COPD. There are 2 types of bronchodilators: short acting and long acting.

Short-acting bronchodilators (SABD)

Short-acting bronchodilators are primarily used as needed for symptom relief or prior to performing an activity / task that you know will cause symptoms. They are usually taken before exercise or to rapidly reduce coughing and shortness of breath during an exacerbation (flare-up). Although these inhalers are great for quick use, the effects don’t last long term.

 

Common short-acting bronchodilators include:

• Ventolin® Diskus®
• Ventolin® MDI
• Atrovent® MDI
• Bricanyl® Turbuhaler®
• Combivent Respimat®

 

Short-acting bronchodilators can cause mild side effects including increased heart rate, shakiness, cough, headache, and dry mouth. However, these side effects should go away over time.

Long-acting bronchodilators (LAMA or LABA)

Long-acting bronchodilators are intended for general maintenance. These inhalers are meant to be taken once or twice daily and have a prolonged effect that lasts between 12 to 24 hours. This form of medication works gradually to help ease breathing, so it’s important to use these types of inhalers consistently. They don’t act as quickly as short-acting bronchodilators, so they are not meant to be used during emergency situations.

There are 2 types, Long-Acting Beta-Agonist (LABA) and Long-Acting Muscarinic Antagonist (LAMA). They both accomplish the same thing—keeping the airways dilated—but they accomplish it by differents means. The LABA causes smooth muscle relaxation and helps dilate the airways. Meanwhile, the LABA blocks the receptors responsible for smooth muscle contraction.

 

Common long-acting bronchodilators include:

• Spiriva® HandiHaler®
• Spiriva® Respimat®
• Serevent® Diskus®
• Onbrez® Breezhaler®
• Seebri® Breezhaler®
• Incruse™ Ellipta®
• Tudorza® Genuair®

 

The most common side effects caused by these inhalers include dry mouth, headaches, and tremors.

Anti-inflammatory drugs

Anti-inflammatory drugs decrease swelling in the airways to make it easier to breathe. As a result, they improve the passage of air and help reduce symptoms like coughing and shortness of breath. After consistent usage, this decrease in inflammation also helps lower mucus production. These medications can be inhaled or taken as oral or IV medication (more on corticosteroid pills later in the article).

Inhaled Corticosteroids (ICS)

Inhaled corticosteroids are a type of anti-inflammatory medication that is prescribed in combination with a long-acting bronchodilator for the treatment of COPD. Corticosteroids reduce inflammation, making it easier for air to travel through the lungs. Always rinse your mouth and spit after the use of an ICS as it will help prevent hoarseness, throat irritation, and infection in the mouth.

Combination inhalers

Combination inhalers contain 2 to 3 types of medication. Combination inhalers can contain a mix of beta-2-agonists, anticholinergics, and inhaled steroids.

 

Common combination inhalers include:

• Advair® Diskus®
• Breo™ Ellipta®
• Symbicort® Turbuhaler®
• Anoro® Ellipta®
• Duaklir® Genuair®
• Inspiolto™ Respimat®
• Ultibro® Breezhaler®
• Trelegy™ Ellipta®

 

There are so many inhalers to choose from, and the options can seem overwhelming. Your health care provider will help you select which inhaler is best for you based on your symptoms, the cost, the convenience, and the ease of use of each device. On the plus side, there are lots of options, so if one doesn’t work, there are others to try!

List of COPD Medications

COPD Medications

How to use a MDI inhaler?

Inhalers may seem simple, but they are actually difficult to use properly. Proper inhaler technique is crucial to ensure you receive the adequate dose of medication to optimize your symptoms. An MDI (Metered-Dose Inhaler) is a common type of puffer, however, there are also many other types of puffers and inhalers on the market.

Make sure you ask your health care provider or pharmacist to show you how to properly use these devices.

1. If the inhaler is new or has not been used in a while, pump 2–3 pumps into the air to prime the device.
2. Use a spacer device/AeroChamber/valved chamber with your inhaler. This is a plastic tube where you insert your inhaler into one end and breathe into the other. A spacer device helps you get two to three times more medication than if you were to place the puffer directly in your mouth. This is because the chamber suspends the medication rather than the medication depositing into your cheeks and the back of your throat.
3. Shake your inhaler well for 5–10 seconds.
4. Insert your puffer into your spacer device.
5. Exhale fully.
6. Seal your lips around the spacer device. Pump the inhaler, inhale slowly and smoothly, then hold your breath for 5–10 seconds. Exhale slowly.
7. Wait 60 seconds and repeat for the prescribed number of puffs. Check your COPD action plan for instructions.
8. If there is a steroid medication in your puffer, rinse your mouth out well with water to prevent thrush.
9. Regularly clean your spacer device with gentle soap and water, then air dry.

Oral medications

Antibiotics
Some bacterial or viral infections can cause your COPD to worsen or lead to an acute exacerbation. There are a variety of antibiotics that can be used to treat COPD exacerbations including:

• Amoxicillin
• Sulfamethoxazole-trimethoprim
• Azithromycin
• Doxycycline
• Cefuroxime
• Amoxicillin-clavulanate
• Ceftriaxone
• Levofloxacin

 

Typically, your doctor will vary the type of antibiotic you receive as repeated use of the same antibiotic can lead to antibiotic resistance over time. This means that the bacteria can become immune to that type of antibiotic and the drug will no longer work. In some cases where people have very frequent COPD exacerbations, a respiratory specialist will instruct them to take a very small dose of an antibiotic every day.

 

Corticosteroids
In addition to the inhaled medications discussed earlier, corticosteroids also come in pill form, commonly known as prednisone. Corticosteroids are generally used as a short-term treatment for emergency purposes during a COPD exacerbation. The most common side effects of corticosteroids include sleep disturbances, headaches, weight gain, muscle weakness, and an upset stomach.

 

Mucolytics
If you have frequent flare-ups or excess mucus, your doctor may prescribe a medication called N-acetylcysteine (NAC or Mucomyst) to help liquefy your secretions (phlegm or mucus). When secretions are thinner, they are easier to cough out. This results in an easier clearance of mucus out of your lungs and improves your breathing.

 

Other anti-inflammatory drugs
Other types of oral anti-inflammatory drugs, like methylxanthines (Theophylline) or phosphodiesterase inhibitors (Roflumilast), are taken orally once a day. They are typically only prescribed in more severe cases of COPD.

Nebulizer treatment

Nebulization is an alternative delivery method for some of the common COPD medications.

 

With this type of device, medication is transformed into a fine mist that you breathe in through a mask or mouthpiece.

 

This allows the medication to be delivered into your lungs without the use of a conventional inhaler.

Want to know more?

Reach out to a pharmacist, doctor, or respiratory therapist with any questions you may have. Additionally, you can find helpful information through a pulmonary rehabilitation program.