Update on pharmacologic therapy for chronic obstructive pulmonary disease

Formoterol

Inhaled formoterol is a long-acting selective beta2-adrenoceptor agonist, with an onset of action of 5 minutes postdose and a bronchodilator effect that lasts for at least 12 hours. Statistically significant and clinically relevant (>120 ml) improvements in lung function [assessed using standardized/normalized area under the forced expiratory volume in 1 second (FEV1) versus time curve (AUC FEV1)] were observed with inhaled formoterol 12 microg twice daily (the approved dosage in the US) compared with placebo in 12-week and 12-month, randomized, double-blind trials in patients with chronic obstructive pulmonary disease (COPD). The bronchodilator efficacy of formoterol 12 microg twice daily was greater than that of oral slow-release theophylline (individualized dosages) in a 12-month trial or inhaled ipratropium bromide 40 microg four times daily in a 12-week trial. Improvement in AUC FEV1 with formoterol, but not theophylline, compared with placebo was observed in patients with irreversible or poorly-reversible airflow obstruction. Formoterol also significantly improved health-related quality of life compared with ipratropium bromide or placebo and significantly reduced symptoms compared with placebo. Combination therapy with formoterol 12 microg twice daily plus ipratropium bromide 40 microg four times daily was significantly more effective than albuterol (salbutamol) 200 microg four times daily plus the same dosage of ipratropium bromide in a 3-week, randomized, double-blind, double-dummy, crossover trial. Inhaled formoterol was well tolerated in clinical trials. The incidence of investigator-determined drug-related adverse events with inhaled formoterol 12 microg twice daily was similar to that with placebo and inhaled ipratropium bromide 40 microg four times daily but lower than that with oral slow-release theophylline (individualized dosages). Importantly, there were no significant differences between formoterol and placebo or comparator drugs in cardiovascular adverse events in patients with COPD and corrected QT interval values within the normal range. In conclusion, inhaled formoterol improved lung function and health-related quality of life and reduced symptoms relative to placebo in clinical trials in patients with COPD. The drug had greater bronchodilator efficacy than oral slow-release theophylline or inhaled ipratropium bromide and showed efficacy in combination with ipratropium bromide. The adverse events profile (including cardiovascular adverse events) with formoterol was similar to that with placebo. Thus, inhaled formoterol may be considered as a first-line option for the management of bronchoconstriction in patients with COPD who require regular bronchodilator therapy for the management of symptoms.

Tiotropium bromide

Therapy with bronchodilators forms the pharmacologic foundation of the treatment of patients with COPD. Bronchodilators can significantly lessen dyspnea, increase airflow, improve quality of life, and enhance exercise performance. While bronchodilators decrease airway resistance and lessen dynamic hyperinflation in patients with COPD, they have not been shown to alter the rate of decline in FEV₁ over time, or improve patient survival. Fairly recently, a long-acting, once-daily anticholinergic medication, tiotropium bromide, has been developed which may improve symptom management in COPD patients. This paper reviews anticholinergic pharmacologic therapy for patients with COPD focusing on tiotropium bromide, and discusses treatment strategies based on disease stage. It is important to recognize that while bronchodilators improve symptoms, a multimodality treatment approach including respiratory and rehabilitative therapy, nutrition services, psychosocial counseling, and surgical care, is often necessary for the best possible care of patients with COPD.

Acute Exacerbation of COPD

Nurses in acute care settings play a vital role in caring for individuals during an acute exacerbation of chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the United States. In addressing this health concern, the Global Initiative for Chronic Obstructive Lung Disease Report summarized the goals for COPD management and recommended treatment supported by current data and research. It is imperative that our clinical nursing practice is based upon research-supported interventions: use of appropriate medications, monitoring acid-base status, administering controlled oxygen therapy, assessing the need for mechanical ventilation, and close monitoring of comorbid illnesses. Health promotion includes patient and family education on early recognition of symptoms, smoking cessation strategies, and participation in pulmonary rehabilitation that can reduce long-term morbidity from this chronic disease.

Pharmacologic treatment of chronic obstructive pulmonary disease: past, present, and future

Pharmacologic treatment of chronic obstructive pulmonary disease (COPD) has evolved considerably during the past several decades. Initial treatment of the disease was accomplished primarily through antibiotics, mucolytic agents, and nonselective sympathomimetic agents. Up-to-date treatment guidelines stratified according to strength of evidence are published in the National Heart, Lung, and Blood Institute-World Health Organization workshop report on the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease. Current drug therapy for stable COPD focuses primarily on bronchodilation through inhaled beta2-agonists and anticholinergic agents, immunization, and elimination of smoking as a risk factor. Although many pharmacologic agents are available to treat COPD, no drug has demonstrated effectiveness in halting progression of the disease. Rather, the goal of drug therapy at this time is to maintain control of symptoms and prevent COPD exacerbations. Compared with asthma, research into treatment for COPD has been minimal. However, a long-acting anticholinergic agent, tiotropium, has received approval status by the United States Food and Drug Administration. The drug has been shown to improve spirometric parameters, quality of life, and utilization of health care resources. In addition, several new targets for the treatment of COPD are being studied, and a few agents, including some that theoretically may slow functional decline in patients with COPD, are in development.

Advances in the management of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a progressive and irreversible airflow limitation with extreme economic and social burden. It is estimated that over the next two decades, it will become the 5(th) most prevalent disease and the 3(rd) most common cause of death in the world. A better understanding of the pathogenesis of airway inflammation and alveolar destruction allows for the development of new therapeutic targets. Tobacco smoking is the most important risk factor in the development of COPD, thus making smoking cessation of the outermost importance. This article provides a critical review of present therapy for COPD. In addition to conventional treatment (bronchodilators, corticosteroids and antibiotics) and smoking cessation therapies, novel approaches with potential benefit are discussed.

Mood disorders and chronic obstructive pulmonary disease: current research and future needs

The following review examines the interrelationships between chronic obstructive pulmonary disease (COPD), psychiatric illness, and tobacco use. The influence that these three entities have is very unclear, and this article attempts to address the current knowledge of how each contributes to the other and postulates future directions to explore regarding diagnosis, treatment, and predictive values. Other issues discussed include the pharmacologic treatment of patients with COPD and depression, and an overview of the clinical trial data regarding several different classes of antidepressants. Also reviewed is the impact of pulmonary rehabilitation on psychologic status and quality of life issues in the daily functioning of the COPD patient.

Recent advances in diagnosis and management of chronic bronchitis and emphysema

Chronic obstructive pulmonary disease is a progressive inflammatory disease of the airways and lung parenchyma. Expiratory airflow limitation is the hallmark of chronic obstructive pulmonary disease. It is a significant cause of morbidity and mortality in the United States and worldwide and results in a large consumption of health care resources. Unfortunately, despite efforts to curb this disease, its prevalence is increasing. The diagnosis is usually made when the patient complains of dyspnea on exertion; by this time, irreversible structural damage to the lung has already occurred. Given the nonspecific symptoms of the disease and the inability to effectively treat and reverse the damage, it is essential to diagnose the disease in its early stages and take the necessary preventive measures, thus avoiding disability or death. This review summarizes the latest developments in the diagnosis and management of chronic obstructive pulmonary disease. The first half of the review discusses functional, radiographic, biochemical, and cellular/histopathologic issues in the diagnosis of chronic obstructive pulmonary disease. The second half focuses on the current pharmacologic and nonpharmacologic advances in chronic obstructive pulmonary disease, including the role of respiratory support and surgical treatment. Based on the research on the cellular mechanisms of chronic obstructive pulmonary disease, the review also makes a reference to novel and experimental therapies for chronic obstructive pulmonary disease.