COPD Treatment

 

QALY = Quality adjusted life years.

 

So, first treatments are not about prescribing.

1. Treat Tobacco dependency
2. Offer Flu and pneumococcal vaccinations
3. Optimise BMI (if possible, or at least start the discussion)
4. Promote exercise and offer pulmonary rehab if MRC > or = 3
5. Before starting or changing any inhalers, assess inhaler technique 
6. Check how many rescue packs issued in last 6 months - if >2 

SABA - Short Acting Beta Antagonist:

• Salbutamol  - Salamol easibreathe or Ventolin accuhaler
• Terbutaline - Bricanyl Turbohaler

LAMA - Long Acting Muscarinic Antagonist (better)

• Tiotropium - Braltus DPI capsules or Spiriva Respimat
• Aclidinium - Eklira Genuair

LABA - Long acting Beta Antagonist

• Salmeterol - Serevent Accuhaler or Soltel
• Formoterol - Easyhaler or Oxis Turbohaler or timos Modulite

LAMA/LABA - Long Acting Muscarining Antagonist combined with  Long acting Beta Antagonist

• Aclidinium & Formoterol - Duaklir Genuair
• Indacaterol & Glycopyrronium - Ultibro
• Tiotropium & Olodaterol - Spiolto Respimat 

Triple therapy

• ICS/LABA/ LAMA (Trilegy /Trimbow)

ICS

• Asmabec - beclomethasone Qvar - beclomethasone
• Clenil beclometahsone 
• Kelhale - beclomethasone 
• Pulmicort - budesonide
• ciclesonide
• Flixotide - fluticasone
• mometasone.

ICS/LABA

• Formoterol with budesonide
  • DuoResp Spiromax® 160/4.5 —  2 inhalations twice daily
  • Symbicort Turbohaler® 400/12 — one puff twice daily
  • Fobumix® 160/4.5 Easyhaler — 2 inhalations twice daily
  • DuoResp Spiromax ® 320/9 — 1 inhalation twice daily
  • Fobumix® 320/9 Easyhaler9 — 1 inhalation twice daily
  • Symbicort® 200/6 pressurised inhaler — 2 inhalations twice daily
  • Symbicort 200/6 Turbohaler® — 2 puffs twice daily
  • Other combinations of formoterol with budesonide are available but are not currently licensed for use in COPD.
• Formoterol with beclometasone
  • Fostair NEXThaler® 100/6— 2 inhalations twice daily.
  • Fostair® 100/6 — 2 inhalations twice daily.
  • Clinicians should be aware that Fostair® is more potent than traditional beclometasone dipropionate CFC-free inhalers — dose of beclometasone dipropionate in Fostair® should be lower than non-extra-fine formulations and will need to be adjusted to the individual.
• Formoterol with beclometasone and glycopyrronium
  •  2 inhalations twice daily.
• Salmeterol with fluticasone
  • Seretide 500 Accuhaler® — one inhalation twice daily.
  • AirFluSal Forspiro® — 1 inhalation twice daily.
  • Other combinations of salmeterol with fluticasone are available but are not currently licensed for use in COPD.

 COPD with breathlessness

1. SABA (salbutamol/terbutaline)
2. if needing SABA daily add LAMA (Tiotropium/Aclidinum) or switch to LABA (Salmeterol/Formoterol)
3. If continued breathlessness switch to LAMA/LABA Duaklir/Ultibro/Spiolto combination 

NICE (2018) says add LABA/LAMA combination first line, rather than after trying individual agents but BTS/SIGN and PCRS disagree as some patients do benefit, at least for some time, on single agents.

LABA (Salmeterol/Formoterol)OPD with exacerbations 

• defined as 2 or more iexacerbations in a year, or one that requires Hospital admission, whether breathless or not

1. SABA (salbutamol/terbutaline) & either LAMA (Tiotropium/Aclidinum) or LABA (Salmeterol/Formoterol)
2. If continued exacerbations or breathlessness add LABA/LAMA combination
3. If still poorly controlled, STOP, THINK, Take Stock, consider referral
4. Consider triple therapy
   • ICS and LABA/LAMA or ICS/LABA and separate LAMA (Tiotropium/Aclidinum) or NEW TRIPLE THERAPY PRODUCT

 COPD with Asthma - ACO (Asthma COPD Overlap)

1. Step 1, 2 or 3 then treat with SABA SABA (salbutamol/terbutaline) and ICS & LAMA (Tiotropium/Aclidinum) but there are none on the local formulary so these have to be given as separate inhalers, so QVAR or Clenil and either Aclidinium or Tiotropium.
2. If still poorly controlled, STOP, THINK, Take Stock, consider referral.
3. Consider triple therapy
4. If no response to escalation to top level, then consider stepping down again AND referring to respiratory service.

 

Carbocysteine capsules (Mucodyne)

• only to reduce sputum viscosity
• 375mg x2, tds
• Contraindicated if active or history of ulcers
• review after a month - if the sputum is improving, then they can be continued but should be reduced to 2 capsules bd as soon as feasible, but must be stopped if not improving sputum viscosity symptoms.