Preventing Acute Exacerbations of COPD

New COPD Treatment Recommendations Published

Experts_Jose-Luis-Pelaez-Inc_Blend-Images.jpg
Photo Credit: Jose Luis Pelaez Inc/Blend Images.

COPD is a chronic, lifelong disease. Patients who have COPD often experience periods of dramatic worsening of symptoms that may come on relatively quickly (called an acute exacerbation).   Acute exacerbations frequently manifest as episodes of worsening cough, shortness of breath or mucus production.  Patient may wheeze and feel chest tightness.  These symptoms should prompt a visit to the physician and if severe, may result in hospitalization.

  Unfortunately, even when treated, lung function does not always recover back to baseline after an acute exacerbation, leaving patients with worsened symptoms.

These hospitalizations are burdensome not only for the patients who suffer from these episodes, but are also one of the leading expenses associated with COPD.  In fact, it’s estimated that up to $30 billion dollars are spent on costs directly associated with COPD, and most of that cost is due to acute exacerbations.  In Canada, approximately $700 million dollars are spent per year on expenses that result from acute exacerbations.

Clearly, preventing acute exacerbations is a high priority for patients and for society.  There is extensive research being done all over the world to learn more about how to prevent these exacerbations and reduce the number of hospitalizations patients with COPD require.

In the recent edition of the medical journal Chest, which is one of the leading medical journals in the field of Pulmonary and Critical Care medicine, an Executive Summary was released that outlines 33 recommendations for the prevention of acute COPD exacerbations.

  The recommendations were based on scientific evidence that was reviewed and agreed upon by a panel of leading COPD experts.

This article summarizes those recommendations, but before diving in, it’s important to remember that these are recommendations and not absolute rules since all patients are individuals and may have special circumstances or concerns.

Here is a summary of the most important recommendations:

  • All patients with COPD should receive pneumococcal vaccination.
  • All patients with COPD should get the annual influenza vaccine.
  • Smoking cessation counseling and treatment should be offered to all patients. It is important to note that quitting smoking is the only intervention known to improve outcomes by slowing the decline of lung function and reducing the symptoms of COPD.
  • Patients with moderate, severe, or very severe COPD who have had an exacerbation within the last month should undergo pulmonary rehabilitation.
  • Patients who have experienced a COPD exacerbation should have education, case management, a written action plan, and direct access to a specialist at least monthly to prevent exacerbations.
  • Patients should be on a long-term macrolide (ie. azithromycin) if: they have moderate to severe COPD, have a history of moderate or severe exacerbations in the last year and are already on inhaler therapies (see below). Note that the purpose of this medication in this context is to reduce inflammation and not to treat infection.
  •  Patients with acute exacerbations of COPD should receive oral or IV steroids.
  • Patients who have moderate to severe chronic bronchitis and an exacerbation in the last year should receive roflumilast.
  • Patient with stable COPD may have reduced exacerbations when using slow-release theophylline (it is important that this medication requires frequent monitoring with blood testing and has side effects that often preclude use.
  • Patients with moderate to severe COPD and a history of more than 2 exacerbations may have less exacerbations if treated with oral N-acetylcysteine.
  • Patients with stable COPD may have decreased exacerbations if treated with oral carbocysteine. Note, this is not based on robust evidence but rather expert consensus.
  • Statin medications (ie. lipitor, zocor) are not recommended to prevent COPD exacerbations.

In terms of inhaler therapies, the recommendations get a little complicated, but here are the take-away points that have the strongest scientific evidence:

Remember, these are recommendations and not absolute rules since all patients are individuals and may have special circumstances or concerns.  Most patients should not be on all the medications described above. Talk to your doctor if you have questions about your medications

REFERENCE:

1.    Criner GJ, Bourbeau J, Diekemper RL, et al. Executive Summary: Prevention of Acute Exacerbation of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline. Chest 2015;147:883-93.

Continue Reading