COPD: Could You Be At Risk?
Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on Oct 31, 2020.
COPD: A Deadly and Costly Problem
Chronic obstructive pulmonary disease, or COPD, is a lower respiratory (lung) disease. This group of diseases ranks 4th among leading causes of death in the U.S., according to the Centers for Disease Control and Prevention (CDC).
COPD includes emphysema and chronic bronchitis, and most deaths, around 80%, result from cigarette smoking.
- Chronic obstructive pulmonary disease (COPD) is a debilitating lung condition that affects 1 in 8 Americans age 45 and older. More than 16 million Americans have been diagnosed with COPD, and millions more have it but don’t know it, based on NIH data.
- Annualized costs due to COPD in 2020 are estimated to run close to $49 billion.
- Workplace costs add up, too: COPD caused roughly 16.4 million days of lost work, costing an extra $4 billion, according to the CDC.
- Over 76% of costs due to COPD are paid for by the Medicare or Medicaid.
It's obvious COPD is an important medical concern. But what exactly is COPD?
COPD Defined: Lung Damage
COPD is actually a group of disorders that damage the lungs, impair airflow, and make breathing progressively more difficult over time.
- In emphysema, the walls between the air sacs in the lungs are damaged; they lose their shape, become larger, and can fill with mucus.
- In chronic bronchitis, the lining of the airways is irritated and inflamed and also thickens with mucus.
In both instances, coughing is common and breathing becomes difficult.
Most people who have COPD have both emphysema and chronic bronchitis; therefore, the more broad term COPD is used.
COPD is not reversible, but medications can reduce symptoms.
Top Risk Factors for COPD
- Tobacco Smoking
- Indoor and outdoor air pollution
- Toxic gases, chemicals or dust in the workplace
- Chronic respiratory illnesses
- Secondhand smoke
- A twin sibling with emphysema (emphysema can be genetic)
Although COPD symptoms worsen over time, treatment can control symptoms and often limit rapid disease progression.
COPD: Signs and Symptoms
Symptoms of COPD due to smoking tend to begin at age 50 or 60, and will worsen unless the smoker quits. Symptoms include:
- Morning cough, with mucus, which may progress to a persistent cough
- Wheezing, shortness of breath, barrel-shaped chest
- Chest tightness, lung infections
- Fatigue, weight loss
- Bluish skin tint due to lack of oxygen
- Eventual heart failure
How Will Your Doctor Diagnosis COPD?
- Your doctor will look for signs and symptoms of COPD, such as those mentioned on the previous slide.
- In addition to some possible blood work to measure oxygen and carbon dioxide in the blood, lung functions tests, like spirometry, may be ordered. During a spirometry test, you breath into a special machine that measures how well your lungs are working.
- X-rays or a test that measures the electrical activity of the heart called an electrocardiogram (ECG or EKG) may be ordered.
- Your lung mucus may be sent to the lab to be analyzed for bacteria to determine if you need an antibiotic.
The First Step: You Must Quit Smoking
The most common cause of COPD is tobacco smoking. If smoking is the cause of your COPD, you need to quit.
- Many patients may have tried to quit smoking in the past and failed.
- Do NOT let past failed attempts discourage you.
- Nicotine is addictive and hard to stop, but not impossible. Quitting will prolong your life.
Talk to your doctor about nicotine replacement products or other treatments such as Chantix (varenicline) or bupropion. These agents can be very helpful to reduce cravings and reach your goal to quit smoking.
Smoking cessation products are often used together with behavior modification and counseling support groups to help you stop smoking. Used together, these methods can be successful.
Treatments for COPD: Short-Acting Beta-2 Agonists
The first, and most important, step in treatment of COPD is to quit smoking.
When medicines become necessary, single therapy with short-acting bronchodilators (beta-2 agonists) is often the first treatment for mild, intermittent COPD symptoms. Bronchodilators open the airways, help decrease secretion, and are the cornerstone of treatment for COPD.
Albuterol's effect lasts 4 to 6 hours after inhalation. Common brand names of albuterol include:
Bronchodilators come as inhalers; both albuterol and Xopenex also come as nebulized solutions for those who have trouble using inhalers.
Ipratropium: Another Short-Acting Bronchodilator
Another option besides a short-acting beta-2 agonist for bronchodilation is an anticholinergic agent.
Ipratropium (Atrovent HFA) is a short-acting anticholinergic that acts as a bronchodilator and helps to dry secretions. In general, short-acting beta-2 agonists will have a faster onset of action than anticholinergic agents, but tolerance to beta-2 agonists (a reduced effect over time) may occur.
For added acute relief, a beta-2 agonist, like albuterol, can be combined with ipratropium. such as in Combivent Respimat.
Both metered dose inhalers and nebulized solutions are available and are usually given 4 times a day.
Long-Acting Agents for COPD
For patients with more moderate to severe chronic breathing difficulty, use of a longer-acting anticholinergic and/or beta-2 agonist is recommended and can be more convenient.
Long-acting anticholinergics include:
- aclidinium (Tudorza Pressair), taken twice a day
- umeclidinium (Incruse Ellipta) or tiotropium (Spiriva), inhaled once a day
- glycopyrrolate (Seebri Neohaler), given twice a day via a low resistance inhaler.
- glycopyrrolate (Lonhala Magnair Starter Kit), given twice-daily via the Magnair nebulizer.
Long-acting beta-2 agonists, such as salmeterol (Serevent Diskus), formoterol (Foradil, Perforomist), and arformoterol (Brovana) have a 12-hour effect. Newer agent olodaterol (Striverdi Respimat) is used once a day.
Glycopyrrolate and formoterol fumarate (Bevespi Aerosphere), approved in May 2016 is given twice a day from a pressurized metered-dose inhaler.
In March 2019 the FDA approved the anticholinergic and long-acting beta agonist Duaklir Pressair (aclidinium and formoterol fumarate), for the long-term, maintenance treatment of COPD. It is given as one inhalation two times each day from a breath-actuated multi-dose dry powder inhaler.
Long-acting beta-agonists can be used as a single treatment option (monotherapy) in COPD, but when used alone (without an inhaled corticosteroid anti-inflammatory) in the treatment of asthma, they have been linked with an increased risk of death.
Lonhala Magnair Cleared as Nebulized Option for COPD
Lonhala Magnair (glycopyrrolate) from Sunovion, is a long-acting muscarinic antagonist (LAMA) bronchodilator for the long-term, maintenance treatment of patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema. It was FDA approved in December 2017.
- Lonhala Magnair was the first nebulized, LAMA treatment option for COPD. The technology is based on the use of the Magnair, a quiet, closed system nebulizer that is designed to deliver the drug in 2 to 3 minutes and allows people to breathe normally while using the device. It is dosed two times a day, at the same time of the day.
- In Phase 3 placebo-controlled studies in moderate-to-severe COPD, Lonhala Magnair demonstrated statistically significant changes from baseline in trough forced expiratory volume in one second (FEV1) at Week 12.
- Lonhala Magnair does not relieve sudden symptoms of COPD and should not be used more than twice daily. Always have a short-acting beta2-agonist with you to treat sudden symptoms.
Combining Long-Acting Drugs in COPD
As with the short-acting agents, long-acting anticholinergics and beta-2 agonists can be combined in patients not adequately controlled with either agent alone.
- It is a combined treatment of umeclidinium, an inhaled anticholinergic that relaxes the muscles around the airways, and vilanterol, a long-acting beta-2 agonist (LABA) that aids breathing by relaxing airways to allow more air to flow into and out of the lungs.
- The dose is one inhalation once a day, at the same time every day, from the Ellipta inhaler.
Adding an Anti-inflammatory Agent
As a patient with COPD worsens to the severe stage, the addition of an inhaled corticosteroid agent can be added as double or even triple therapy with beta-2 agonists and anticholinergics.
Inhaled corticosteroid monotherapy is not approved in COPD as it is in asthma, but individual inhalers can be combined with other therapies, examples include:
- QVAR Redihaler (beclomethasone inhalation)
- Pulmicort Flexhaler (budesonide inhalation)
- Flovent Diskus (fluticasone inhalation)
- Asmanex Twisthaler (mometasone inhalation)
Fluticasone or budesonide, both anti-inflammatory corticosteroids, are also available with beta-2 agonists in combined inhalers:
- fluticasone and salmeterol (Advair Diskus, AirDuo RespiClick, Wixela Inhub, and generics)
- fluticasone and vilanterol (Breo Ellipta)
- budesonide and formoterol (Symbicort)
While Advair and Symbicort are inhaled twice a day, Breo Ellipta is dosed once a day.
A Triple Agent: FDA Approves Trelegy Ellipta
In September 2017 the FDA approved GSK’s Trelegy Ellipta (fluticasone furoate, umeclidinium and vilanterol), the first dry powder inhaled corticosteroid, long-acting muscarinic antagonist (LAMA) and long-acting beta2-adrenergic agonist (LABA) combination for patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema.
This agent puts three COPD medications into one inhaler: a LAMA, a LABA and a corticosteroid. The dose is one inhalation once daily. View more prescribing information on Trelegy Ellipta here.
Trelegy Ellipta is for used for two groups of patients:
- either those on a fixed-dose combination of fluticasone/vilanterol (Breo Ellipta) who need additional bronchodilation
- or those who are already using Breo Ellipta and Incruse Ellipta
In clinical studies, the most common side effects occuring in greater than or equal to 1% of patients (at least 1 out of every 100 patients) included: headache, back pain, dysgeusia (altered taste), diarrhea, cough, throat pain, and upset stomach.
In September 2020, Trelegy Ellipta was also approved for the maintenance treatment of asthma in adults.
Breztri Aerosphere: A New Triple Agent
In July 2020, the FDA approved AstraZeneca’s Breztri Aerosphere, a metered dose inhaler for the maintenance treatment of patients with COPD.
- Breztri combines 3 medicines in one inhaler: budesonide (an inhaled corticosteroid), glycopyrrolate (an anticholinergic agent for bronchodilation) and formoterol fumarate (a long-acting beta2 agonist that relaxes the smooth muscles lining the airways).
- It is given as two inhalations twice daily.
FDA approval was based on positive results from two Phase 3 studies where researchers found a significant reduction in the rate of the primary endpoint, moderate or severe exacerbations, when compared with dual-combination therapies Bevespi Aerosphere (glycopyrrolate and formoterol fumarate) and PT009 (budesonide and formoterol fumarate).
Breztri Aerosphere is not approved for use in the treatment of asthma or acute bronchospasm.
Daliresp: An Oral Tablet Option for COPD Inflammation
A COPD flare can last for weeks and increase the risk of death.
- Daliresp reduces lung inflammation, but is not a bronchodilator and will not treat an acute attack; bronchodilators should be used in combination.
- Daliresp comes as an oral 500 microgram (mcg) tablet dosed once a day. Lower 250 mcg doses may used for treatment initiation to enhance tolerability, but not for maintenance therapy, as the lower dose is not effective.
- In clinical trials, some common side effects with Daliresp were diarrhea, nausea, headache, but weight loss and behavioral changes have been seen, too.
COPD Inhalers: What Are Their Side Effects?
Most beta-2 agonists inhalers are well-tolerated by COPD patients, but there can still be side effects you should be aware of:
- fast heart rate
- muscle tremors
- difficulty sleeping
Discuss use of beta-2 agonists with your doctor if you have heart disease. Tolerance to beta-2 agonist can occur, too, meaning the therapeutic effect may diminish over time.
Anticholinergic agents like ipratropium can cause: dry mouth, throat irritation and elevated intraocular (eye) pressure. Anticholinergics should be used cautiously in those with glaucoma or prostate gland enlargement.
Inhaled corticosteroids can cause: oral yeast infections (thrush), throat irritation, headaches, possible increased risk of pneumonia. Rinsing your mouth after use of an inhaled corticosteroid can lower the risk of thrush.
Always discuss any possible side effects with your doctor before you start treatment.
Approved: Once-Daily Yupelri (revefenacin) for COPD
Inhalers are commonly used in COPD, but some COPD patients may prefer a nebulized solution over an inhaler for ease of use.
In November 2018, Theravance Biopharma and Mylan N.V. announced the FDA approval of Yupelri (revefenacin), a once-daily nebulized inhalation solution for the maintenance treatment of patients with chronic obstructive pulmonary disease (COPD).
- Yupelri is the first once-daily, nebulized bronchodilator approved for the treatment of COPD in the U.S. It is classified as a long-acting muscarinic antagonist (LAMA), considered a first-line agent for patients with COPD. Lonhala Magnair is a nebulized LAMA but is dosed twice daily.
- In Phase 3 studies when Yupelri was compared to placebo, Yupelri led to significant improvements in lung function (FEV1, OTE FEV1) after 12 weeks of dosing.
- In clinical trials, common side effects included cough, upper respiratory tract infection, headache, and back pain.
Other Treatments for COPD
In severe COPD, the use of oxygen may be needed. Oxygen can improve quality of life and prolong survival. All COPD patients should receive influenza and pneumococcal vaccines.
When COPD exacerbations occur, a short-term course of oral corticosteroids, such as prednisone, may be needed. Slow-release theophylline can be used as a bronchodilator in COPD, but therapeutic serum levels need to be followed.
Pulmonary rehabilitation may be added to medical treatments. Pulmonary rehabilitation is a weekly outpatient program that encourages exercise, good nutrition, education, breathing techniques, and counseling to enhance the ability to function.
What Additional COPD Resources Are There?
- In addition to asking questions of your health care providers, you can review information from the COPD Foundation to learn more and stay involved in your condition.
- The NIH has released The COPD National Action Plan. Developed at the request of Congress and with input from the broad COPD community and patients, the Action Plan describes how we can all work together to raise awareness about COPD and reduce its impact.
- Support groups, like the COPD Maintenance Support Group on Drugs.com can be a great source for learning how others cope with their COPD, voicing concerns and reviewing the latest COPD news.
- Finally, the American Lung Association is a reliable source of timely information on COPD and additional tips on ways to quit smoking and beat the habit.
Finished: COPD: Could You Be At Risk?
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