PULMONOLOGY |
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Regular treatment with inhaled corticosteroids improves symptoms, lung function, and quality of life, and reduces the frequency of exacerbations in COPD patients with an FEV1 < 60 % predicted. |
occur within the therapeutic range of serum theophylline.
These medications also have significant interactions with commonly used medications such as digitalis, coumadin, etc. Unlike the other bronchodilator classes, xanthine derivatives may involve a risk of overdose( either intentional or accidental).
Combination bronchodilator therapy
Combining bronchodilators with different mechanisms and durations of action may increase the degree of bronchodilation for equivalent or lesser side effects. For example, a combination of a short-acting beta 2
-agonist and an anticholinergic produces greater and more sustained improvements in FEV1 than either drug alone and does not produce evidence of tachyphylaxis over 90 days of treatment.
The combination of a beta 2
- agonist, an anticholinergic, and / or theophylline may produce additional improvements in lung function and health status. Short-term combination therapy using formoterol and tiotropium has been shown to have a bigger impact on FEV1 than the single components. Combinations of shortacting beta 2
-agonists and anticholinergics are also superior compared to either medication alone in improving FEV1 and symptoms. Combinations of a long-acting beta 2
-agonist and a long-acting anticholinergic have shown a significant increase in lung function whereas the impact on patient reported outcomes is still limited.
There is still too little evidence to determine if a combination of long-acting bronchodilators is more effective than a longacting anticholinergic alone for preventing exacerbations.
Corticosteriods Inhaled corticosteroids
The dose-response relationships and long-term safety of inhaled corticosteroids in COPD are
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not known. Only moderate to high doses have been used in long-term clinical trials. The efficacy and side effects of inhaled corticosteroids in asthma are dependent on the dose and type of corticosteroid, but whether this is also the case in COPD is unclear. The effects of corticosteroids on pulmonary and systemic inflammation in patients with COPD are controversial, and their role in the management of stable COPD is limited to specific indications.
Regular treatment with inhaled corticosteroids improves symptoms, lung function, and quality of life, and reduces the frequency of exacerbations in COPD patients with an FEV1 < 60 % predicted.
Withdrawal from treatment with inhaled corticosteroids may lead to exacerbations in some patients, although in another study with severe and very severe COPD patients, inhaled corticosteroids could be gradually withdrawn over a three- month period without increasing the medium term risk of exacerbations, although lung function deteriorated significantly.
Withdrawal of inhaled corticosteroids, in COPD patients at low risk of exacerbation, can be safe provided that patients are left on maintenance treatment with long-acting bronchodilators. Regular treatment with inhaled corticosteroids does not modify the long-term decline of FEV1 nor mortality in patients with COPD.
Combination inhaled corticosteroid / bronchodilator therapy
An inhaled corticosteroid combined with a long- acting
beta 2
-agonist is more effective than the individual components in improving lung function and health status and reducing exacerbations in patients with moderate to very severe COPD.
An inhaled corticosteroid / longacting beta 2
-agonist combination given once daily does not show
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relevant differences regarding efficacy compared to twice daily. A large prospective clinical trial failed to demonstrate a statistically significant effect of combination therapy on mortality, but a subsequent meta-analysis found that combination therapy may reduce mortality with a number needed to treat( NNT) of 36 254.
Combination therapy is associated with an increased risk of pneumonia, but no other significant side effect. The addition of a long-acting beta 2
- agonist / inhaled corticosteroid combination to tiotropium improves lung function and quality of life and may further reduce exacerbations, but more studies of triple therapy are needed.
Oral corticosteroids
Oral corticosteroids have numerous side effects. An important side effect of longterm treatment of COPD with systemic corticosteroids is steroid myopathy, which contributes to muscle weakness, decreased functionality, and respiratory failure in subjects with very severe COPD.
In view of the well-known toxicity of long-term treatment with oral corticosteroids, prospective studies on the long-term effects of these drugs in COPD are limited. However, systemic corticosteroids for treating acute exacerbations have been shown to improve symptoms, lung function, reduce rate of treatment failure, and shorten length of hospital stay.
The effect of preventing a subsequent exacerbation has been shown in a pooled data analysis and it was demonstrated that systemic corticosteroids when being used to treat acute exacerbations can reduce 30- day readmission rates due to recurrent exacerbations.
Phosphodiesterase-4 inhibitors
The principal action of
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10 | May 2017 |
The Specialist Forum | Vol. 17 No. 4 |