Practical Pearls from the GOLD Guidelines on COPD

By Juan Garcia, MD, FCCP; and Stephen Jenkinson, MD, FCCP

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Manage Stable COPD

The overall approach to managing stable COPD should be characterized by a stepwise increase in treatment, depending on the severity of the disease. A number of different types of pharmacologic agents are used to treat patients with COPD, and patients in GOLD Stage II or greater should receive daily bronchodilator therapy. Pharmacologic therapy is used to prevent and control symptoms, reduce the frequency and severity of exacerbations, improve health status, and improve exercise tolerance. Initial use should decrease airways obstruction and decrease dyspnea. None of the existing medications for COPD has been shown to alter the long-term decline in lung function that occurs with COPD. These various medications, however, can be used to decrease morbidity and may also delay disability and mortality in some patients. Medications may also decrease the number of exacerbations of COPD occurring each year.

Pearl: In general, nebulized therapy is not needed for a stable patient unless it has been demonstrated to be more effective than conventional metered-dose or dry powder inhaler dose therapy in that particular patient. It can also be considered for the patients who are unable to properly use inhalers.

Pearl: Combinations of bronchodilators with different mechanisms and durations of action tend to increase the degree of bronchodilation in COPD patients with increases in FEV₁, FEV₁/FVC, and peak expiratory flow. Changes in pulmonary function are not directly additive with an increasing number of bronchodilators being administered, but combinations usually do increase pulmonary function significantly more than administering each agent alone. Use of combination therapy is recommended as COPD advances beyond Stage II. Long-acting inhaled bronchodilators are more convenient to the patient.

Pearl: Tiotropium, a long-acting anticholinergic, has been shown in clinical trials to be more beneficial than ipratropium in improving exacerbations, dyspnea, quality of life, and lung function in patients with COPD.8,9 It is expected to be approved by the Food and Drug Administration by July 2003.

Pearl: Mast cell stabilizers such as cromolyn sodium or nedocromil sodium should not be used to treat COPD. Leukotriene modifiers such as zileuton, zafirlukast, or montelukast also should not be used to treat COPD because there are no data to suggest efficacy.

Pearl: If you have a patient receiving theophylline, any time a new medication is added, someone in your office must review the new drug to make sure it does not cause hepatic P-450 inhibition, which could ultimately result in theophylline toxicity.

Pearl: Systemic steroids are clinically beneficial to patients hospitalized with a COPD exacerbation, and maximum effects of oral steroids after 3 days of IV steroids are achieved within 2 weeks. Longer tapering schedules increase steroid side effects without significantly improving lung function.

Pearl: In trials of inhaled steroids, there was a tendency for exacerbations of COPD to be less severe and exacerbation rates to have been decreased by as much as 25%. The use of inhaled corticosteroids in COPD does not decrease the rate of decline of the patient’s FEV₁ over time, but may decrease the decline in their health status.

Pearl: Inhaled corticosteroids may reduce the risks of repeated hospitalizations and death in elderly patients with COPD.¹⁰

Pearl: Inhaled corticosteroids should be considered for patients with repeated exacerbations requiring treatment with oral steroids, and/or patients with objective evidence (increase in FEV₁ > 200 mL and 15% above baseline) of response to a trial of inhaled corticosteroids (6 of 12 weeks). The FEV₁ in these patients should be < 50% of predicted.

Pearl: Influenza vaccination is recommended. It can reduce death and serious disease in patients with COPD.

Pearl: Antibiotics: The use of antibiotics, other than in treating infectious exacerbations of COPD or other bacterial infections, such as pneumonia, is not recommended. Antitussives: The regular use of antitussives is contraindicated in stable COPD. Mucolytic agents: Although a few patients with viscous sputum may benefit from mucolytics, the overall benefits seem to be very small. Therefore, the widespread use of these agents cannot be recommended on the basis of the present evidence. Narcotics: Narcotics are contraindicated in COPD because of their respiratory-depressant effects and potential to worsen hypercapnia. Clinical studies suggest that morphine use to control dyspnea may have serious adverse effects, but it may provide benefits to a limited number of patients.

Pearl: Long-term oxygen therapy is generally introduced in the GOLD Stage III patient who has: (1) PaO2 ≤ 55 mm Hg or arterial oxygen saturation ≤ 88% on room air, with or without hypercapnia; or (2) PaO2 < 60 mm Hg or arterial oxygen saturation ≤ 89% on room air, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive heart failure, or polycythemia (hematocrit > 55%). In these patients, long-term oxygen therapy improves survival.

Pearl: Pulmonary rehabilitation should be considered for patients with moderate or severe COPD. Exercise tolerance and symptoms improve with these programs.¹¹

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