Inhaled respiratory medicines: optimising use in COPD

The management of veterans with chronic obstructive pulmonary disease (COPD) often requires the use of several inhaled medicines presented in various types of inhaler devices. In addition, COPD may overlap with asthma, increasing the potential for the use of multiple respiratory medicine devices. A number of recently published guidelines, including COPDX¹ and GOLD² have addressed the overall management of COPD. This therapeutic brief focuses on optimising the use of respiratory medicines and ensuring good compliance and inhaler technique for your veteran patients.

Complex medication regimens have the potential to cause problems in administration and compliance for the patient.

Maximising the clinical effectiveness and minimising the adverse effects of inhaled medicine depend on good compliance and technique.

In the twelve months from September 2004 approximately 70,000 (1 in 5) veterans were dispensed at least one respiratory medicine for COPD or asthma.³ Over 45% of these veterans were dispensed two or more distinct types of inhaler devices.³

Selection of the most appropriate medicine

Beta-agonist and anticholinergic bronchodilators are first-line therapy in COPD. Bronchodilators do not slow the progression of COPD and are primarily used to improve symptoms, exercise tolerance and quality of life. Table 1 shows the COPDX¹ classification of disease severity and suggests initial treatment with short-acting bronchodilators. However, FEV₁ correlates poorly with symptoms and treatment with bronchodilators is usually driven by functional assessment rather than spirometric results.

Table 1: Initial treatment with short-acting bronchodilators.¹

Severity of COPD	FEV1	Suggested treatment
Mild	60-80%	Intermittent bronchodilator – salbutamol (2 puffs x 100µg) or ipratropium bromide (2 puffs x 20 µg) prior to exercise as needed.
Moderate	40-59%	Intermittent or regular bronchodilator – salbutamol (2 to 4 puffs x 100 µg qid) or ipratropium bromide (2 puffs x 20 µg qid). Combination bronchodilators may be considered (eg Combivent®).
Severe	<40%	Regular combined bronchodilator - salbutamol (2 to 4 puffs x 100 µg qid) and ipratropium bromide (2 to 4 puffs x 20 µg qid).

Many veteran patients will already have moderate to severe COPD, and in this group regular treatment with long-acting bronchodilators may be more effective and is more convenient than treatment with the short-acting preparations.^2,4

Despite a lack of large, long-term studies examining the use of tiotropium in combination with long acting beta₂-agonists (LABAs),^5,6 these agents work by different mechanisms and guidelines advocate combined bronchodilator therapy for patients who do not respond satisfactorily to initial monotherapy.^1,2

There is conflicting evidence regarding the efficacy of inhaled corticosteroids (ICS) to slow decline in lung function.⁷ There is some evidence that long-acting bronchodilators and ICS can reduce exacerbation rates in patients with moderate to severe COPD.^4,8-13

The inflammatory process in COPD (neutrophil dominant) is different from that of asthma (mast cell, eosinophil dominant). This difference explains why ICS provide much better symptom relief and improvement in FEV₁ in asthma than in COPD. In COPD, ICS should be considered in patients:

• with a documented positive response (symptoms or FEV₁) during a 2-3 month trial of use; or
• in patients who have severe COPD with frequent exacerbations (> 2 per year).^1,4

There is mounting evidence that a short course of oral glucocorticosteroids is a poor predictor of the long-term response to inhaled glucocorticosteroids in COPD.^2,4 A trial of ICS is warranted even if a patient has not previously responded to oral therapy.

Review, step-down or cease

The clinical effectiveness of each inhaled medicine should be reviewed within 2 to 3 months of commencement.

Check compliance and inhaler technique. Consider ceasing the medicine if there is no improvement of symptoms, functional status, or lung function (as measured by spirometry).

Optimising inhaler technique

Veterans need to be provided with the knowledge and skills to use their inhaler devices safely and effectively.

The veteran community is particularly vulnerable to problems with medicines, as many veterans have poor eyesight, tremor, and coordination difficulties. In addition, cognitive impairment may compromise a patient’s ability to effectively use an inhaler device.^1,4

Many veterans are dispensed multiple respiratory devices concurrently. This may add to the problems experienced by veterans in administration and compliance with their medicine.

Training the patient using the relevant package insert plus physical demonstration significantly improves patient technique.¹⁵

The patient should demonstrate appropriate technique to the doctor/pharmacist at the time of consultation.

Inhaler technique may begin to decline two months after patient education.⁵ Therefore, it is important to reinforce correct technique when the patient is reviewed.

A yearly medication review presents an opportunity to critically assess inhaler technique. This should be supplemented by additional review at each medical consultation and at the time of any acute exacerbation or evidence of disease destabilisation.

HMRs are an effective means of educating veterans in the use of their respiratory medicine devices and should be considered for all patients.

For recommendations and counselling tips for individual inhaler devices please refer to Table 2 (see PDF).

Acute exacerbations of COPD

Good inhaler technique and compliance is an essential element in reducing exacerbations.

Exacerbations of COPD cause:^16,17

• accelerated deterioration in lung function,
• increased morbidity and progressive loss of independence,
• increased mortality rates,
• hospitalisation.

Reducing frequency of exacerbations

There is some evidence that both long-acting bronchodilators and inhaled corticosteroids, either alone or together, reduce exacerbations in patients with moderate to severe COPD.^4,8-13

Combination therapy with inhaled corticosteroids and LABAs show significant effects on the prevention of acute exacerbations. Emerging data are expected to clarify the role of ICS in the management of patients with COPD of different severities, as well as the place of treatment with ICS/LABA combinations.¹⁸

Immunisation

Immunisation against influenza and pneumococcal pneumonia is recommended to reduce acute exacerbations of COPD.^2,4,11

Antibiotics

Current evidence does not support long-term antibiotic use to prevent exacerbations in patients with COPD. However, they should be used in exacerbations with an increase in cough, dyspnoea, sputum volume or purulence.¹

Oral corticosteroids

The use of oral corticosteroids in the treatment of exacerbations of COPD is well established. However, long-term treatment with oral glucocorticosteroids should be avoided because of an unfavourable benefit-to-risk ratio.²

Smoking cessation

Immediate implementation of an effective smoking cessation program is essential for the successful management of COPD.^4,19

Visit www.quit.org.au

Smoking cessation is the only intervention shown to slow the deterioration in lung function.^20-22 No medicine has been conclusively shown to slow the progression of COPD.

Figure reproduced from COPDX guidelines²

Smoking cessation or a significant decrease in smoking does not lead to recovery of lung function; however, it does cause the accelerated annual rate of decline in FEV₁ to revert toward that of a non-smoking subject and it reduces mortality.²³ The beneficial effects of smoking cessation in slowing the decline in lung function and the progression of disease have been clearly established.²⁴

Other interventions

All patients with COPD should consider being immunised against influenza and pneumococcal-related infections to reduce the frequency of acute exacerbations.

Ensure patients understand that at different times they may require different medicines to manage their COPD. All patients should have an action plan for management of acute exacerbations.

Pulmonary rehabilitation plus long term maintenance exercise programs and optimised medical treatment can lead to significant reductions in the frequency of acute exacerbations, hospitalisations, and premature mortality.²³ Comprehensive programs incorporating exercise, education, smoking cessation, nutritional counselling, and psychosocial support provide the greatest benefit.

What to tell your patient

• To regularly check their inhaler technique with you and their pharmacist.
• To know when their inhaler needs replacing and how best to store the medicine.
• HMRs can help them get the best results from their inhalers.
• To seek help early if they are feeling worse. Early intervention may reduce the need for hospitalisation.
• To stop smoking as it is the only intervention that will slow the progression of the disease.
• To develop an exercise and nutrition program, together with their health care team.

References

1. Australian Lung Foundation. The COPDX Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2003. Med J Aust, 2003. 178 Suppl: p. S7-39.
2. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Available at: www.goldcopd.com
3. Veterans Datamart, University of South Australia, QUMPRC. Accessed Dec 2005.
4. National Institute of Clinical Excellence Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Clinical guideline 12, 2004. Available at www.nice.org.uk
5. Therapeutic Guidelines Ltd. Therapeutic Guidelines Respiratory, Version 3. North Melbourne: Therapeutic Guidelines Ltd, 2005
6. Aaron SD et al. The Canadian Optimal Therapy of COPD Trial: design, organization and patient recruitment. Canadian Respiratory Journal 2004;11(8):581-585.
7. Highland, K.B., Inhaled corticosteroids in chronic obstructive pulmonary disease: is there a long-term benefit? Curr Opin Pulm Med, 2004. 10(2): p. 113-9.
8. Sin, D.D., et al., Contemporary management of chronic obstructive pulmonary disease: scientific review. JAMA, 2003. 290(17): p. 2301-12.
9. Burney, P., et al., The pharmacoepidemiology of COPD: recent advances and methodological discussion. Eur Respir J Suppl, 2003. 43: p. 1s-44s.
10. Cooper, C.B. and D.P. Tashkin, Recent developments in inhaled therapy in stable chronic obstructive pulmonary disease. BMJ, 2005. 330(7492): p. 640-4.
11. Man, S.F., et al., Contemporary management of chronic obstructive pulmonary disease: clinical applications. JAMA, 2003. 290(17): p. 2313-6.
12. Rennard, S.I., Treatment of stable chronic obstructive pulmonary disease. Lancet, 2004. 364(9436): p. 791-802.
13. Sin, D.D. and S.F. Man, Inhaled corticosteroids in the long-term management of patients with chronic obstructive pulmonary disease. Drugs Aging, 2003. 20(12): p. 867-80.
14. Roughead EE, Barratt JD, Gilbert AL. Medication-related problems commonly occurring in the Australian community setting. Pharmacoepidemiology Drug Safety 2004;13:83-87
15. Basheti I et al. Counseling About Turbuhaler Technique: Needs Assessment and Effective Strategies for Community Pharmacies. Respiratory Care, 2005, 50(5): 617-623
16. Blanchard, A.R., Treatment of acute exacerbations of COPD. Clin Cornerstone, 2003. 5(1): p. 28-36.
17. Niewoehner, D.E., Interventions to prevent chronic obstructive pulmonary disease exacerbations. Am J Med, 2004. 117 Suppl 12A: p. 41S-48S.
18. Selroos O. The place of inhaled corticosteroids in chronic obstructive pulmonary disease. Current Medical Research and Opinion 2004;20(10):1579-1593.
19. Ramsey, S.D. and S.D. Sullivan, Chronic obstructive pulmonary disease: is there a case for early intervention? Am J Med, 2004. 117 Suppl 12A: p. 3S-10S.
20. Pauwels, R.A. and K.F. Rabe, Burden and clinical features of chronic obstructive pulmonary disease (COPD). Lancet, 2004. 364(9434): p. 613-20.
21. Barnes, P.J., Therapy of chronic obstructive pulmonary disease. Pharmacol Ther, 2003. 97(1): p. 87-94.
22. Decramer, M., et al., Effect of treatments on the progression of COPD: report of a workshop held in Leuven, 11-12 March 2004. Thorax, 2005. 60(4): p. 343-9.
23. Doherty, D.E. and D.D. Briggs, Jr., Chronic obstructive pulmonary disease: epidemiology, pathogenesis, disease course, and prognosis. Clin Cornerstone, 2004. Suppl 2: p. S5-16.
24. Altose, M.D., Approaches to slowing the progression of COPD. Curr Opin Pulm Med, 2003. 9(2): p. 125-30.

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