Medication for COPD

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

Beta-2 agonists form the basis of treatment with medication in COPD. They 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 also lasts longer: about 12 to 14 hours, depending on the exact medication used.

If the COPD is only causing mild symptoms, 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. It is important to always carry the inhaler with you. If the symptoms get worse over time, using a long-acting beta-2 agonist over the long term can help. The medication is inhaled once in the morning and once in the evening. This relieves breathing problems and prevents acute episodes of shortness of breath (flare-ups or exacerbations).

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

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

Anticholinergics can also 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 possible side effect of anticholinergics is a dry mouth. They are otherwise considered to be well tolerated.

Steroid medications are used as needed in addition to bronchodilators. They can improve your breathing somewhat. But they mainly reduce the risk of acute breathing problems. For this reason, steroid inhalers are usually only used in the long term by people with severe COPD and frequent breathing problems.

Steroid inhalers may slightly increase the risk of pneumonia and oral thrush, though. Both of these occur in about 1 out of 100 people per year. Another possible side effect of steroid inhalers is a hoarse voice. So it's recommended that you rinse your mouth or brush your teeth after using the inhaler.

If severe symptoms don’t improve, steroids can also be temporarily taken in the form of tablets. Then it’s important to use the lowest possible dose.

The potential 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 become weaker too. Because of this, long-term treatment with steroid tablets is not recommended.

PDE4 inhibitors can be taken as tablets in addition to bronchodilators. Roflumilast is the only PDE4 inhibitor that is recommended for the treatment of COPD. It reduces the inflammation in the bronchi. This can make it easier to breathe and prevent acute breathing problems. Roflumilast is only recommended if the symptoms keep on suddenly getting worse despite regularly using controller medication.

Research has shown that PDE4 inhibitors can somewhat improve breathing and quality of life, but they also have side effects:

• They prevented episodes of acute breathing problems in about 5 out of 100 people.
• About 5 to 10 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.

Biologics have been available for the treatment of COPD since 2024. They can be used if treatment with a combination of a long-acting beta-2 agonist, a steroid medication and a long-acting anticholinergic hasn't relieved the symptoms enough. Biologics reduce inflammation in the bronchi, which reduces the risk of acute breathing problems.

Biologics are available in the form of pre-filled syringes. They are injected under the skin in the belly or thigh every few weeks.

Yes. Depending on the stage of the COPD, it can be helpful to combine two bronchodilators (like a beta-2 agonist and an anticholinergic). These kinds of combinations are often more effective and have fewer side effects than a higher dose of one of the medications alone. If there are still frequent flare-ups, then a triple combination with a steroid or with roflumilast is possible. A biologic drug may be used on top of that, too.

Mucolytics aim to break up the phlegm in the airways, making it easier to cough it up. Research has shown that mucolytics lower the risk of acute breathing problems in people who have chronic bronchitis and COPD. They were found to prevent acute breathing problems in about 13 out of 100 people per year.

But mucolytics do not improve breathing otherwise. They are not often used in the treatment of COPD.

People who have COPD are especially susceptible to complications caused by the flu. They can get a flu vaccine every year in the fall. Research has 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 also possible.

People with COPD can be vaccinated against pneumococcus bacteria too. These bacteria can cause inflammations in the lungs, the middle ear, the sinuses and other places in the body. People with COPD are more likely than others to get pneumonia and have acute breathing problems if they're infected with pneumococcus bacteria. The pneumococcal vaccine can lower this risk somewhat. The vaccine has a protective effect for about five years and then you need to have another dose ("booster shot").

Experts also recommend getting vaccinated against COVID-19 and RSV (respiratory syncytial virus).

Infections in the airways can lead to acute breathing problems 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 coughed-up phlegm that is greenish-yellow in color or contains pus.

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

In rare cases, antibiotics may be used as a preventive measure to lower the number of flare-ups.