Medication for COPD

Photo of two women talking (PantherMedia / Tomas Anderson)

Medication is an important part of the daily treatment of chronic obstructive pulmonary disease (COPD). Although it can't cure the condition, it can help relieve the symptoms and prevent acute breathing problems.

The possible treatment options mainly depend on the severity of the disease. In early stages of COPD, people usually only need to take medication when they have acute breathing problems. As the symptoms become more frequent and more severe, certain drugs need to be taken regularly. People who have advanced COPD often take several medications at the same time.

The following medications are typically used:

  • Drugs that open up the airways (bronchodilators): beta-2 agonists, anticholinergics, and methylxanthines if needed
  • Anti-inflammatory drugs: drugs containing steroids (corticosteroids) and PDE4 inhibitors

Other drugs called mucolytics are used to dissolve mucus in the bronchi and make it easier to cough it up as phlegm. Antibiotics are sometimes used to relieve acute breathing problems. Flu vaccines or pneumococcal vaccines can prevent additional infections that may make the breathing problems worse.

Bronchodilators

There are various kinds of bronchodilators, including beta-2 agonists, anticholinergics, and methylxanthines. These medications are usually inhaled. They relax the muscles in the bronchi, allowing the narrowed airways to open up.

Beta-2 agonists

Beta-2 agonists form the basis of treatment for COPD. These medications can be divided up into two groups: short-acting beta-2 agonists and long-acting beta-2 agonists. The short-acting group includes fenoterol, salbutamol and terbutaline, and the long-acting group includes formoterol and salmeterol. The short-acting beta-2 agonists (SABAs) are used when needed, such as during acute breathing difficulties. They work fast, but the effect only lasts for four to six hours. Long-acting beta-2 agonists (LABAs) are taken regularly. It takes longer for them to start working, but the effect lasts for about 12 hours.

In early-stage COPD, it is usually enough to use a short-acting beta-2 agonist as needed. Sudden shortness of breath can usually be quickly relieved by inhaling this medication. If the symptoms get worse over time, regularly using a long-acting beta-2 agonist can help. This relieves breathing problems and prevents acute episodes of shortness of breath (flare-ups or exacerbations). Studies have shown that beta-2 agonists can improve people's lung function and quality of life.

The medications prevented flare-ups too.

  • Without beta-2 agonists, 7 out of 100 people had to go to the hospital in the space of six months because of severe breathing difficulties.
  • This was the case in 5 out of 100 people who took beta-2 agonists.

In other words: In this period of time, the medications prevented a severe flare-up requiring a hospital stay in 2 out of 100 people. They prevented moderate flare-ups as well.

Normal doses of beta-2 agonists are usually well tolerated, but high doses can cause side effects such as a rapid pulse, palpitations or tremors.

Anticholinergics

Anticholinergics are about as effective as beta-2 agonists. They also come in short-acting and long-acting forms. The effects of long-acting anticholinergics like tiotropium bromide last for about 24 hours, which is longer than most beta-2 agonists do. This means that they only need to be inhaled once a day. Short-acting anticholinergics only start working after 20 to 30 minutes, but the effect then lasts up to eight hours.

Like beta-2 agonists, anticholinergics can reduce the risk of flare-ups. As a result, people who use anticholinergics need to go to the hospital less often and their quality of life improves.

One side effect of anticholinergics is a dry mouth. They are otherwise regarded as well-tolerated.

Methylxanthines

Methylxanthines also widen the airways. Theophylline is the most commonly prescribed methylxanthine. It is usually taken as a tablet.

Theophylline is less effective at relieving symptoms than beta-2 agonists and anticholinergics are, and it has more side effects. Because of this, it is usually only recommended if treatment with beta-2 agonists and anticholinergics isn't effective enough.

The possible side effects of theophylline include headaches, insomnia, an irregular heartbeat, heartburn and nausea. High doses may also cause seizures. Older people in particular often don't tolerate these drugs well.

Steroid medication

Steroid inhalers

Steroid medication is taken as needed in addition to bronchodilators. It doesn't have much of an effect on daily symptoms, but can lower the risk of flare-ups. For this reason, steroid inhalers are usually only used in the long term by people with severe COPD and frequent breathing problems.

Previous research has shown that steroid inhalers are only effective at doses of over 1,000 micrograms per day. But such high doses of steroids also increase the risk of pneumonia. Within one year, inhaled steroids

  • prevented one or more flare-ups in about 5 out of 100 people, and
  • caused pneumonia in about 1 out of 100 people.

Another side effect of steroid inhalers is oral fungal infections, which occur in about 5 out of 100 people per year. Hoarseness also occurs in about the same number of people. So it's recommended that you rinse your mouth or brush your teeth after using the inhaler.

Steroid tablets

Steroids can also help speed up recovery from a flare-up with acute breathing difficulties, but they are then taken as tablets or injected.

The possible side effects of taking steroid tablets over a longer period of time include weight gain, increased blood sugar levels and trouble sleeping. If the tablets are taken for a very long time, your skin, muscles, and bones may be weakened, too. Long-term treatment with steroid tablets is therefore not recommended.

PDE4 inhibitors

PDE4 inhibitors can be taken as tablets in addition to bronchodilators. They reduce the inflammation in the bronchi. This can make it easier to breathe and prevent flare-ups.

Studies have shown that PDE4 inhibitors can improve breathing and quality of life:

  • These medications prevented flare-ups with worse breathing difficulties in about 5 out of 100 people.
  • About 5 out of 100 people had side effects such as nausea and diarrhea, loss of appetite, weight loss, sleep problems and headaches.

It is still not clear how well PDE4 inhibitors work compared to steroids, so they are currently rarely used.

Further options

Mucolytics

Mucolytics are said to relieve coughs with excessive phlegm (sputum) by dissolving the phlegm in the airways, making it easier to cough it up. Studies on mucolytics have produced inconsistent results. Mucolytics might be able to decrease the risk of flare-ups with worse breathing difficulties in people who have a cough with a lot of phlegm. But they do not improve breathing otherwise. They are not often used in the treatment of COPD.

Vaccination

People who have COPD are especially susceptible to complications caused by the flu. They can get a flu vaccine every year in the fall. Studies have shown that this vaccination decreases the risk of COPD flare-ups and respiratory infections such as bronchitis or pneumonia.

The flu vaccine is given as an injection. The most common side effects are redness and swelling where the vaccine was injected. Temporary tiredness, headaches and a mild fever are possible too.

Vaccinating against pneumococcus bacteria is also an option. These germs can cause inflammations in the lungs, the middle ear, the sinuses and other places. People with COPD are more likely than others to get pneumonia and have acute breathing problems if they are infected with pneumococcus bacteria. The pneumococcal vaccine can lower this risk somewhat. The vaccine has a protective effect for about five years and then it needs to given again ("booster shot").

Antibiotics

Respiratory infections can cause acute shortness of breath in people with COPD. If the infection was caused by bacteria and the symptoms are very severe, antibiotics can help. One sign of a bacterial infection is sputum that is greenish-yellow in color or contains pus.

Antibiotics won't help if the infection is caused by viruses. They may also cause diarrhea and other side effects.

Combining drugs

Depending on the stage of COPD, it may be a good idea to combine two medications that expand the airways (such as a beta-2 agonist and an anticholinergic). Such combinations are often more effective and have fewer side effects than a higher dose of one of the medications on its own.

Labels: Airways and respiratory system, Chronic obstructive pulmonary disease (COPD), J42, J43, J44, J96, Pulmonary disease, chronic obstructive (COPD), Pulmonary emphysema, R05, R06