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COPD: Could You Be At Risk?

Medically reviewed on Sep 28, 2017 by L. Anderson, PharmD

COPD: A Deadly and Costly Problem

Chronic obstructive pulmonary disease, or COPD, is a lower respiratory (lung) disease and ranked 3rd 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 percent, result from smoking.

Annualized costs due to COPD in the year 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. But what exactly is COPD?

COPD Defined: Lung Damage

Image: National Heart, Lung, and Blood Institute

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.

Why COPD? 6 Top Risk Factors

  • Tobacco Smoking
  • Indoor and outdoor air pollution
  • Toxic gases, chemicals or dust in the workplace
  • Chronic respiratory illnesses
  • Secondhand smoke
  • A twin 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: 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 Zyban (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 to help you stop smoking.

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.

Common brand names of albuterol include ProAir HFA, Proventil, Ventolin; albuterol's effect lasts 4 to 6 hours. Maxair (pirbuterol) also lasts 4-6 hours. Xopenex (levalbuterol) lasts 6 to 8 hours. Bronchodilators come as inhalers; both albuterol and Xopenex come as nebulized solutions for those who have trouble using inhalers.

Ipratropium: Another Short-Acting Bronchodilator

Another option besides short-acting beta-2 agonists 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 (less effect over time) to beta-2 agonists may occur. For added acute relief, a beta-2 agonist, like albuterol, can be combined with ipratropium (brand names include Combivent, Combivent Respimat, DuoNeb). 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, or umeclidinium (Incruse Ellipta ), tiotropium (Spiriva), inhaled once a day, or glycopyrrolate (Seebri Neohaler), given twice a day via a low resistance inhaler. Long-acting beta-2 agonists, such as salmeterol (Serevent Diskus), formoterol (Foradil, Perforomist), and arformoterol (Brovana) have a 12-hour effect. Newer agents, indacaterol (Arcapta) and olodaterol (Striverdi Respimat) are used once a day. Glycopyrrolate/formoterol fumarate (Bevespi Aerosphere), approved in May 2016 is given twice a day from a pressurized metered-dose inhaler. Long-acting beta-agonists have not been linked with an increased risk of death in COPD, but are in asthma.

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. Anoro Ellipta 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. In November 2015 FDA approved Utibron Neohaler (glycopyrrolate and indacaterol), a twice-daily, long-acting muscarinic antagonist and beta2-adrenergic agonist (LABA) fixed-dose combination for COPD maintenance treatment.

Fixed-dose triple combination agents of long-acting anticholinergics/long-acting beta-2 agonists/inhaled corticosteroids are currently in development.

Adding an Anti-inflammatory Agent

As COPD worsens to the severe stage, the addition of a 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 (QVAR, Pulmicort, Flovent, Asmanex) can be combined with other therapies.

Fluticasone or budesonide, both anti-inflammatory corticosteroids, are also available with beta-2 agonists in combined inhalers: fluticasone/salmeterol (Advair Diskus), fluticasone/vilanterol (Breo Ellipta), and budesonide/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/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.

Daliresp: An Oral Tablet Option for COPD Inflammation

A COPD flare can last for weeks and increase the risk of death. Roflumilast (Daliresp) is a phosphodiesterse-4 inhibitor approved by the FDA for severe COPD patients to treat flares involving chronic bronchitis. 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 oral tablet dosed once a day.

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?

Always discuss any possible side effects with your doctor. Most inhalers are well-tolerated by COPD patients. With beta-2 agonists, a fast heart rate, muscle tremors, difficulty sleeping, and headache can occur. If you have heart disease, discuss use of beta-2 agonists with your doctor. Tolerance to beta-2 agonist can occur, too, meaning the effect may diminish over time. Anticholinergic agents like ipratropium can cause dry mouth, throat irritation, and elevated eye pressure. Anticholinergics should be used cautiously in those with glaucoma or prostate gland enlargement. Inhaled corticosteroids can cause oral yeast infections, throat irritation, headaches, or a possible increased risk of pneumonia.

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. 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. 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.

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.

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 and blog posts.

Finally, the American Lung Association is a reliable source of timely information and additional tips on ways to quit smoking.

Finished: COPD: Could You Be At Risk?

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Sources

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  • Drugs for asthma and COPD. Treatment Guidelines from the Medical Letter. Vol. 11 (Issue 132). Accessed March 18, 2017 at http://www.medicalletter.org.
  • Chronic Obstructive Pulmonary Disease (COPD). Drugs.com/Harvard Health. Accessed Accessed March 18, 2017 at https://www.drugs.com/health-guide/chronic-obstructive-pulmonary-disease-copd.html
  • Patient information: Chronic obstructive pulmonary disease (COPD) treatments (Beyond the Basics). Up-To-Date. Accessed March 18, 2017 at http://www.uptodate.com/contents/chronic-obstructive-pulmonary-disease-copd-treatments-beyond-the-basics#H1
  • COPD Treatment. COPD Foundation. Accessed March 18, 2017 at http://www.copdfoundation.org/Learn-More/For-Medical-Professionals/Treatment.aspx
  • What is COPD? National Heart, Lung, and Blood Institute (NIH). Accessed March 18, 2017 at http://www.nhlbi.nih.gov/health/health-topics/topics/copd/
  • Global Strategy for diagnosis, management, and prevention of COPD. Accessed March 18, 2017 at http://www.goldcopd.org.
  • Bronchodilators Appear Associated with Increased Risk of Cardiovascular Events. JAMA Intern Medicine. Accessed March 18, 2017 at http://media.jamanetwork.com/news-item/bronchodilators-appear-associated-with-increased-risk-of-cardiovascular-events/
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