Chronic Obstructive Pulmonary Disease Treatment
Introduction
This article will discuss common medications used to treat chronic obstructive pulmonary disease (COPD). Unfortunately, COPD is, at present, a chronic, incurable disease. Thus, a multi-disciplinary approach, which includes education, medication, exercise, breathing retraining, smoking cessation, and appropriate vaccinations against the organisms that cause influenza and pneumoccocal pneumonia, is most likely to yield the best results.
Devices
Before discussing each medicine in detail, let’s look at the different types of devices used to deliver medications.
Metered dose inhaler
One common type of device is called a metered dose inhaler (MDI), sometimes referred to as a puffer. The active medicine in MDIs is delivered in suspension with a propellant, usually freon. The medicine is propelled from the inhaler by squeezing the canister, releasing the suspension into the air, and inhaled into the lungs. The advantage of an MDI is that it deposits the medicine directly in the lung. Therefore, the medicine can provide a greater therapeutic effect while causing fewer side effects in other parts of the body.
However, MDIs have three major drawbacks.
Bad technique
MDIs can be difficult to use, and many patients fail to use proper technique. Important points to remember when using inhalers include:
- shaking the inhaler before use
- inhaling slowly while actuating the device
- holding your breath before exhaling
Failing to coordinate inhalation with the release of the medication is the most common mistake people make with MDI use, or else they breathe in too fast. Either of these mistakes can significantly decrease the amount of medicine delivered to the lungs. If you are using an MDI, you need to practice the correct technique in front of a mirror and with your physician.
If you see the propellant escaping from your mouth into the room, or your doctor notices that your technique is not satisfactory, you might benefit from what is known as a spacer device. This device attaches to the MDI and slows the aerosol release between the device and your mouth. After the medication is released, you are able to wait a second or two before breathing it into your lungs. In addition, many spacers have a flow sensor, which sends you a signal when you are breathing in too fast.
Difficulty remembering to use the MDI
Second, many patients have trouble remembering to use their inhalers consistently. Using an inhaler is not as straightforward as taking a pill, and compliance can be a major problem for patients who need to use a number of MDIs, especially for multiple uses per day. Fortunately, many pharmaceutical companies are aware of this, and a number of new combination products have been developed. In addition, many of these new products are designed to be used twice a day or once a day, allowing for increased convenience.
Freon, an environmental hazard
The third problem with MDIs is the freon propellant. Freon is a substance that can deplete the ozone layer, leading to global warming and other environmental problems. The U.S. and many other freon-producing nations have signed a treaty to phase out its production. Although the implementation of this ban has been delayed for medical products, it is likely that it will be put into effect gradually over the next five years. Thus, pharmaceutical companies will be releasing new medicines in different devices (see powder inhalers below) or in MDIs with alternative propellants. An example of these is Proventil HFA.
Dry powder inhaler
A newer medication now available is called a dry powder inhaler (DPI). In this device, the medicine is available as a powder, either by itself or mixed with a sugar suspension. The particles are of the correct size to deposit in the lung. The device is loaded, the medication is inhaled, and the device is closed. These devices are generally simpler to operate than MDIs, and have proven to be equally effective. However, each device is a little different and specific instructions should be followed for each one. Many of these devices feature counters that alert the patient when they need to be replaced. Some are susceptible to moisture, and should be kept closed and dry. Examples of DPIs available now include Pulmicort, Serevent Rotodisk, and Advair Rotodisk.
Nebulizers
Like the MDI and DPI, the nebulizer is a device that deposits medication into the lungs in aerosol form. A liquid medication is poured into the nebulizer, which uses either forced air or ultrasonic energy to form aerosol droplets. Nebulizers are larger than MDIs or DPIs, and require an energy source or an external supply of compressed air for their operation. Nevertheless, once the medication is loaded, the patient breathes the aerosol normally, making them simple to use, and they are also very effective.
Medications
The following are a series of medications used in the treatment of COPD.
Anticholinergic Drugs
Anticholinergic medications are currently the main stay treatment for patients with COPD. Anticholinergic drugs work by inhibiting a neurotransmitter that causes the airways to constrict as a response to local irritants such as cigarette smoke. Since this medication is inhaled it causes a direct effect on the airway and minimizing side effects through out other parts of the body. The anticholinergic drug most commonly used in patients suffering from COPD is ipratropium bromide. In the summer of 2004 a new anticholinergic drug was introduced called tiotropium bromide brand name Spiriva®. This new drug is provides broncodilation for up to 24 hrs making it suitable for once a day dosing. It was available in the international markets since 2001 but was approved by the FDA in 2004.
Bronchodilators
Bronchodilators are medications used to open up the air passages. They work by relaxing the muscles that are wrapped around the walls of the bronchial tubes, allowing air to move more freely.
Short-acting bronchodilators
Short-acting bronchodilators are fast-acting medications that start working within minutes of inhalation. In general, their effects wear off in four to six hours. Two different types of short-acting bronchodilators are available for treatment, the beta agonists and the anticholinergics. They operate on different receptors on the smooth muscle, (muscle wrapped around the airways in the lung). The beta agonists (e.g. Proventil, Ventolin, Albuterol, Xopenex, Maxair) are the quickest acting medications, but do not last quite a long as the anticholinergic medications (Atrovent). The beta agonists often cause minor side effects that include palpitations, nervousness, and tremors. While side effects are associated with Atrovent (dry mouth, retention of urine, worsening glaucoma), these are very rare, making Atrovent a good first choice.
Both of these medicines are available in MDI and nebulizer form.
Long-acting bronchodilators
Serevent is a new long-acting beta agonist that lasts for twelve hours. It can therefore be used just twice a day with good results. In fact, studies in patients with COPD have shown Serevent to be at least as effective as Atrovent, which is taken four times a day. It does have the side effects associated with beta agonists, including palpitations, nervousness, and tremor. It should not be used as a rescue medication, as the onset of action is prolonged compared to a short-acting beta agonist. Serevent is available as an MDI and a DPI.
Theophyllines
Theophyllines are oral medications available as tablets, capsules, or in syrup form. Brand names include Theodur, Slobid, Slophyllin, Unidur, and Uniphyll. These medications are relatively slow-acting, weak bronchodilators compared to the inhaled medications, but their advantage is that patient compliance is increased.
A major drawback to theophyllines is their safety profile. Side effects of the medicine include nausea and vomiting, restlessness, palpitations, headache, irritability, dizziness, especially if the levels in the bloodstream become too high. Extremely high levels of theophylline can cause seizures and dangerous heart rhythm disturbances. Patients who take this medication must have their blood levels monitored to ensure safety. Furthermore, certain medications can interfere with the elimination of theophylline from the bloodstream, which can lead to increased toxicity. Antibiotics such as Erythromycin, and Ciprofloxicin, and anti-ulcer medications such as Tagamet, can interfere with theophylline elimination.
Inhaled corticosteroids
There are a number of inhaled corticosteroids on the market, including Aerobid, Azmacort, Beclovent, Vanceril, Flovent, and Pulmicort. All are anti-inflammatory agents used to prevent and reduce swelling and inflammation in the bronchial tubes. These medications are not instantaneous bronchodilators; you will not notice the immediate improvement in breathing that you would with the other medicines listed above. These are more preventive medications, designed to prevent exacerbations and attacks of bronchospasm.
Inhaled corticosteroids are unquestionably the most useful medications on the market today to control inflammation in asthma, but the evidence is less clear for COPD. Nevertheless, they are often prescribed to COPD patients. As a group, they are very safe. However, there is concern that high doses of inhaled steroids over a prolonged period can lead to osteoporosis, glaucoma, or cataracts. A small number of patients are at risk of developing a yeast infection in the throat, hoarseness or pain while talking.
Combination drugs
Manufacturers are beginning to create MDI’s, DPI’s and nebulizer vials of drug combinations designed so that patients can take two drugs at once. One of these is Combivent, a combination of Atrovent and albuterol wich seems to work better than either drug taken alone. A second drug combination is Advair, which contains both fluticasone (an inhaled steroid called Flovent) and salmeterol (Serevent). These drugs have proven useful in improving patient compliance.
Antibiotics
There is no role for the chronic use of antibiotics in COPD. Nonetheless, most patients with COPD periodically develop an infectious exacerbation of their disease (bronchitis), characterized by a change in the color of their sputum, increased cough, and increased shortness of breath. Antibiotics are useful in treating these exacerbations. Newer, macrolide antibiotics (Biaxin, Zithromax), cephalosporins (Ceftin, Ceclor), Augmentin, quinolones (Levoquin, Tequin, Cipro) are all good choices to treat the common bacterial pathogens.
Steroid tablets
Oral steroids are also quite useful to treat the exacerbations common in COPD. The medications are typically prescribed for a week or two, and help to reduce the duration and intensity of the exacerbation. A very small minority of patients with COPD may benefit from long-term chronic treatment with oral steroids. However, the side effects of long-term oral steroids are substantial, including osteoporosis, diabetes, weight gain, thinning of the skin, easy bruising, hair loss, cataracts, glaucoma, hypertension, and psychiatric disturbances. Only patients with severe COPD and a clear positive response to these medications should be considered as candidates for this type of therapy.
Other Medications
Leukotriene antagonists are oral medications developed for the treatment of asthma. There are anecdotal reports that they may be useful in COPD, and further evaluation is necessary.
Many physicians use expectorants to help their patients who complain of having difficulty bringing up sputum. Unfortunately, most expectorants have not been carefully studied in rigorous scientific clinical studies, and there is no real solid evidence that they provide any useful benefit to patients with COPD.
Many herbal and alternative therapies are advertised as useful treatments for the symptoms of COPD. Some claim to cure COPD altogether. Unfortunately, COPD, like many chronic diseases, is not curable. None of the herbal remedies that are advertised have been shown to be successful in relieving the symptoms of COPD and, like all herbal remedies, are not carefully inspected and controlled by the Federal Drug Administration.
Conclusion
I have tried to describe the use and side effects of the common medications used to treat COPD. Only you and your physician can fully develop a treatment plan appropriate for your particular needs. Don’t forget about the other aspects of treatment, including smoking cessation, exercise, breathing and relaxation techniques, oxygen therapy, and other modes of therapy. Although COPD cannot be cured, you can live well with a comprehensive approach to its treatment.