PURLs: Consider adding this drug to fight COPD that’s severe (2022)

  • Journal List
  • J Fam Pract
  • PMC4280070

J Fam Pract. 2012 Jul; 61(7): 414–416.

PMCID: PMC4280070

PMID: 22754891

Keia Hobbs, MD and Dionna Brown, MD

Anne Mounsey, MD, PURLS Editor

Anne Mounsey, Department of Family, Medicine, University of North Carolina, at Chapel Hill;

(Video) Endoscopic lung volume reduction for COPD patients: Mayo Clinic Radio

Daily use of azithromycin, in conjunction with the usual COPD regimen, has been found to reduce acute exacerbations in patients with moderate to severe disease.

PRACTICE CHANGER

Consider prescribing daily azithromycin for patients with chronic obstructive pulmonary disease (COPD) and a history of exacerbations—but do a careful risk-benefit analysis first.1

STRENGTH OF RECOMMENDATION

B: Based on one well-designed double-blind, randomized controlled trial (RCT).

Albert RK, Connett J, Bailey WC, et al. Azithromycin for prevention of exacerbations of COPD. N Engl J Med. 2011;365:689-698.

ILLUSTRATIVE CASE

A 65-year-old man with a history of moderate to severe COPD schedules an appointment soon after discharge from the hospital—his second hospitalization for COPD exacerbations in 4 months. The patient uses inhaled glucocorticoids, a long-acting beta-agonist (LABA), and a long-acting anticholinergic. Should you add a macrolide to his medication regimen?

Acute exacerbations of COPD—the third highest cause of death in the United States2—have a major effect on quality of life, often resulting in repeat trips to the emergency department (ED) and numerous hospitalizations, office visits, and days lost from work. According to a new study that used 2006 data, there were 1.25 million hospitalizations for COPD exacerbations that year, with health care costs of $11.9 billion.3 Preventing exacerbations and the associated morbidity and mortality is a major challenge that primary care physicians face.

Can a macrolide help?

Corticosteroids, long-acting beta-agonists (LABAs), and the anticholinergic tiotropium are known to reduce COPD exacerbations,4,5 but what about antibiotics? A Cochrane meta-analysis of 9 RCTs that assessed antibiotic use for COPD found that it did not decrease the number of exacerbations. Notably, however, macrolides were not used in any of the studies.6

Macrolides are known to have anti-inflammatory, antibacterial, and immunomodulatory properties that reduce pulmonary exacerbations in other chronic lung diseases. A recent meta-analysis found that patients with cystic fibrosis have fewer pulmonary exacerbations when they take azithromycin 3 times a week.7

Small studies of the effect of macrolides on the frequency of COPD exacerbations have had conflicting results.8,9 The larger study detailed here evaluated the ability of daily azithromycin therapy to reduce COPD exacerbations.

(Video) Chronic Obstructive Pulmonary Disease (COPD)

STUDY SUMMARY: Daily dose led to fewer exacerbations

This double-blind RCT included close to 1150 participants from 12 US academic health centers, randomly assigned to receive azithromycin 250 mg daily or placebo, in addition to their usual care. (About 10% of patients in both groups died, withdrew, or were lost to follow-up.)

To be included, patients had to be ≥40 years old and have a clinical diagnosis of COPD, defined as a smoking history of 10 pack-years or more, a decreased forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio, and a decreased FEV1 after bronchodilation. In addition, participants had to be on long-term oxygen or have used systemic steroids within the previous year or have had an ED visit or hospital admission for COPD during that time frame. Exclusion criteria included a history of asthma, a resting heart rate >100 beats per minute, a prolonged corrected QT interval (QTc) on electrocardiogram or the use of a medication that might prolong QTc, and a documented hearing impairment.

At baseline, participants were similar in basic demographics, COPD severity, smoking history, and medication use: 49% of those in the azithromycin group and 46% of the placebo group were taking a combination of inhaled corticosteroids, LABAs, and a long-acting anticholinergic medication.

The primary outcome was the time to the first COPD exacerbation. This was defined as ≥3 days with 2 or more COPD symptoms—new onset or worsening cough, dyspnea, sputum production, chest tightness, or wheezing—for which antibiotics or steroids were required. Secondary outcomes were quality-of-life measurements on the St. George’s Respiratory Questionnaire (SGRQ) and the Medical Outcomes 36-item Short Form Health Survey (SF-36). Nasopharyngeal swabs were done every 3 months to check for colonization and resistance. Hearing was assessed with audiometry at the time of enrollment, and again at 3 and 12 months. All patients were followed for a year, with monthly telephone calls or clinic visits, to determine if an exacerbation had occurred in the previous month.

The median time to the first exacerbation in the azithromycin group was 266 days (95% confidence interval [CI], 227-313) vs 174 days (95% CI, 143-215) in the placebo group; P<.001. Frequency of acute exacerbations was 1.48 per patient-year for the azithromycin group compared with 1.83 for the placebo group (relative risk=0.83; 95% CI, 0.72–0.95; P=.01). The number needed to treat to prevent one acute exacerbation in a one-year period was 2.86.

FAST TRACK

The number needed to treat to prevent one acute exacerbation in a one-year period was 2.86.

(Video) Pharmacology: Updates in Guidelines for Chronic Conditions: Chronic Obstructive Pulmonary Disease

There was no significant difference in the SGRQ and SF-36 scores for the azithromycin vs the placebo group. There was a small reduction in unscheduled office visits (0.11 per patient-year; P=.048) in the azithromycin group, and a decrease in hospitalization that was not statistically significant.

Azithromycin group had higher rates of adverse effects

Nasopharyngeal cultures from participants who became colonized during the course of the study found macrolide resistance in 81% of those in the azithromycin group vs 41% of the placebo group (P<.001). Twenty-five percent of patients in the azithromycin group developed measurable hearing loss, compared with 20% of those on placebo (P=0.04; number needed to harm=20).

WHAT’S NEW?: A better understanding of benefits and risks

This study shows that the addition of azithromycin (250 mg/d) to standard COPD treatment decreases the number of exacerbations, but does little to reduce hospital admissions. It also highlights the adverse effect profile of azithromycin and the importance of using the antibiotic only for carefully selected patients.

CAVEATS: Macrolide resistance is a key concern

Twenty-five percent of the azithromycin group had documented hearing loss—an additional one in 20 compared with patients in the placebo group. More importantly, there was an increase in the prevalence of macrolide-resistant respiratory pathogens in patients on daily azithromycin. The long-term impact of daily azithromycin on antibiotic resistance is unknown, both for patients themselves and the community at large.

Physicians will have to assess the benefit of a decrease in COPD exacerbations (approximately one every 3 years) vs the risk of an increase in hearing problems and macrolide resistance. A sensible approach would be to reserve daily use of azithromycin for patients with a history of multiple exacerbations, who potentially have more to gain.

CHALLENGES TO IMPLEMENTATION: There are none

There are no major challenges to implementation aside from the cost, which would be approximately $1200 per year (azithromycin 250 mg [30 tablets] at $98.99 per month).10

Acknowledgments

The PURLs Surveillance System is supported in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.

Contributor Information

Keia Hobbs, Department of Family, Medicine, University of North Carolina at Chapel, Hill.

Dionna Brown, The University of Chicago.

(Video) COPD Exacerbation - CRASH! Medical Review Series

References

1. Albert RK, Connett J, Bailey WC, et al. Azithromycin for prevention of exacerbations of COPD. N Engl J Med. 2011;365:689–698. [PMC free article] [PubMed] [Google Scholar]

2. Centers for Disease Control and Prevention. Injury prevention & control: data & statistics. Available at: http://www.cdc.gov/injury/wisqars/LeadingCauses.html. Accessed April 16, 2012. [Google Scholar]

3. Perera PN, Armstrong EP, Sherrill DL, et al. Acute exacerbations of COPD in the United States: inpatient burden and predictors of cost and mortality. COPD. 2012;9:131–141. [PubMed] [Google Scholar]

4. Jenkins CR, Jones PW, Calverley PM, et al. Efficacy of salmeterol/fluticasone propionate by GOLD stage of chronic obstructive pulmonary disease: analysis from the randomised, placebo-controlled TORCH study. Respir Res. 2009;10:59. [PMC free article] [PubMed] [Google Scholar]

5. Decramer M, Celli B, Kesten S, et al. Effect of tiotropium on outcomes in patients with moderate chronic obstructive pulmonary disease (UPLIFT); a prespecified subgroup analysis of a randomized controlled trial. Lancet. 2009;374:1171–1178. [PubMed] [Google Scholar]

6. Black PN, Staykova T, Chacko EE, et al. Prophylactic antibiotic therapy for chronic bronchitis. Cochrane Database Syst Rev. 2003;(1):CD004105. [PubMed] [Google Scholar]

7. Southern KW, Barker PM, Solis-Moya A, et al. Macrolide antibiotics for cystic fibrosis. Cochrane Database Syst Rev. 2011;(12):CD002203. [PubMed] [Google Scholar]

8. Seemungal TA, Wilkinson TM, Hurst JR, et al. Long-term erythromycin therapy is associated with decreased chronic obstructive pulmonary exacerbations. Am J Respir Crit Care Med. 2008;178:1139–1147. [PubMed] [Google Scholar]

9. Yamaya A, Azuma A, Tanaka H, et al. Inhibitory effects of macrolides on exacerbations and hospitalization in chronic obstructive pulmonary disease in Japan: a retrospective multicenter analysis. J Am Geriatri Soc. 2008;56:1358–1360. [PubMed] [Google Scholar]

10. www.Drugstore.com. Accessed March 28, 2012. [Google Scholar]

Articles from The Journal of Family Practice are provided here courtesy of Frontline Medical Communications Inc.

(Video) Chronic Obstructive Pulmonary Disease: Tools and Resources for Palliative Care

FAQs

What is the best medication for severe COPD? ›

For most people with COPD, short-acting bronchodilator inhalers are the first treatment used. Bronchodilators are medicines that make breathing easier by relaxing and widening your airways. There are 2 types of short-acting bronchodilator inhaler: beta-2 agonist inhalers – such as salbutamol and terbutaline.

Which of the following drug is used in the treatment of COPD? ›

The current pharmacological treatment of COPD is symptomatic and is mainly based on bronchodilators, such as selective β2-adrenergic agonists (short- and long-acting), anticholinergics, theophylline, or a combination of these drugs.

What are 3 treatments for COPD? ›

A variety of medications may be used to treat COPD symptoms.
  • Bronchodilators. Bronchodilators usually come in an inhaler or nebulized form. ...
  • Corticosteroids. ...
  • Antibiotics. ...
  • Smoking cessation medications. ...
  • Anxiolytics (anti-anxiety treatment) ...
  • Opioids.

What is the latest treatment for COPD? ›

It is possible to help patients with Chronic Obstructive Pulmonary Disease with Mesenchymal Stem Cells. When administered intravenously stem cells have the ability to promote healing and regeneration by excreting messenger cells called "cytokines".

What is the best treatment for Stage 4 COPD? ›

Doctors may treat stage 4 emphysema with medication, oxygen therapy, surgery, or a combination.
...
A doctor may prescribe one or more of the following medications:
  • inhaled bronchodilators.
  • anticholinergics.
  • long-acting beta-agonists (LABA)
  • long-acting muscarinic antagonists (LAMA)
  • corticosteroids.
26 Apr 2022

How do you improve severe COPD? ›

If you have COPD , you can take steps to feel better and slow the damage to your lungs:
  1. Control your breathing. ...
  2. Clear your airways. ...
  3. Exercise regularly. ...
  4. Eat healthy foods. ...
  5. Avoid smoke and air pollution. ...
  6. See your doctor regularly.
15 Apr 2020

What is the first line treatment for COPD exacerbation? ›

ANTIBIOTICS. Antibiotic therapy has been shown to have a small but important effect on clinical recovery and outcome in patients with acute exacerbations of chronic bronchitis and emphysema. Therefore, antibiotic administration should be considered at the beginning of treatment for exacerbations of COPD.

Is there any treatment for COPD? ›

Pulmonary rehabilitation (PR for short) is a programme of exercise and education designed for people living with COPD. It's one of the best treatments available for COPD. Ask your doctor or nurse to refer you.

Which is the best inhaler for COPD? ›

Advair is one of the most commonly used inhalers for the maintenance treatment of COPD. It is a combination of fluticasone, a corticosteroid, and salmeterol, a long-acting bronchodilator. Advair is used on a regular basis for the maintenance treatment of COPD and it is typically taken twice per day.

What is the best treatment for stage 3 COPD? ›

People with COPD who have difficulty breathing and frequent infections may take medications to reduce their symptoms. These medications can include: bronchodilators to open up your airways. corticosteroids to decrease swelling and mucus.

What is the gold standard treatment for COPD? ›

LABA + LAMA therapy for COPD

The 2011 GOLD guidelines recognized the importance of LABA + LAMA therapy, which had been shown to improve lung function and hyperinflation more than either drug alone [1]. The combination is only second-line therapy in GOLD 2011, but it is an important combination.

What medications should be avoided with COPD? ›

COPD, such as antibiotics, antimuscarinics, beta-agonists, roflumilast, steroids, and theophylline. Cystic fibrosis, such as antibiotics, cystic fibrosis trans- membrane regulator modulators, mucolytics, and nonsteroidal anti-inflammatory drugs.

Can lung function be restored with COPD? ›

There is no cure for COPD, and the damaged lung tissue doesn't repair itself. However, there are things you can do to slow the progression of the disease, improve your symptoms, stay out of hospital and live longer. Treatment may include: bronchodilator medication – to open the airways.

How long can you last with COPD? ›

Many people will live into their 70s, 80s, or 90s with COPD.” But that's more likely, he says, if your case is mild and you don't have other health problems like heart disease or diabetes. Some people die earlier as a result of complications like pneumonia or respiratory failure.

Can severe COPD reversed? ›

Although COPD can't be reversed, its symptoms can be treated. Learn how your lifestyle choices can affect your quality of life and your outlook.

Can Stage 4 COPD be reversed? ›

It is not currently possible to cure or reverse the condition completely, but a person can reduce its impact by making some treatment and lifestyle changes.

Is Stage 4 COPD reversible? ›

COPD can't be reversed, and it's currently not possible to stop the progression of your COPD completely. You can help you slow the progression of COPD as much as possible by working with your doctor and following a proper treatment program.

How can I stop my COPD from getting worse? ›

9 Tips to Help Slow the Progression of COPD
  1. If You Smoke, Stop. ...
  2. Avoid Breathing in Pollution or Toxins. ...
  3. Enroll in Pulmonary Rehabilitation. ...
  4. Strengthen Your Core. ...
  5. Eat Nutritious Food. ...
  6. Maintain a Healthy Weight. ...
  7. Make Sure You're Taking Your Medicine as Prescribed. ...
  8. Avoid Germs Whenever Possible.
1 Mar 2019

What makes COPD progress faster? ›

If you continue to smoke, your COPD will progress more quickly compared to someone who doesn't smoke. There are treatments to help COPD, but they won't be as effective if you're still smoking.

What treatment slows the progression of COPD? ›

Corticosteroid treatment, however, appears to reduce the frequency of COPD exacerbations and there is some suggestion that it may also reduce the risk of death in patients with severe COPD.

How long does it take to recover from an exacerbation of COPD? ›

Substantial recovery of lung function and airway inflammation occurs in the first week after onset of an AECOPD, whilst systemic inflammatory markers may take up to two weeks to recover. Symptoms generally improve over the first 14 days, however marked variation is evident between studies and individuals.

Why do you not give oxygen to COPD patients? ›

Supplemental O2 removes a COPD patient's hypoxic (low level of oxygen) respiratory drive causing hypoventilation which causes higher carbon dioxide levels, apnea (pauses in breathing), and ultimately respiratory failure. Another theory is called the Haldane effect.

What triggers COPD exacerbation? ›

Exacerbations are usually caused by a viral or bacterial lung infection, but they may also be triggered by things or situations that make it difficult for you to breathe, such as smoking or being exposed to smoke or air pollution. The signs of a COPD exacerbation go beyond your day-to-day COPD symptoms.

Can you live a good life with COPD? ›

Many people are able to maintain a good quality of life while living with chronic obstructive pulmonary disease (COPD).

What is the 3 in one inhaler for COPD? ›

What is TRELEGY? TRELEGY is the first and only once-daily, 3-in-1 treatment for COPD. With 3 medicines in 1 inhaler, TRELEGY can help you breathe easier and improve lung function. It can also help prevent future flare-ups.

How do you get rid of COPD cough? ›

Here are a few easy tips to help you calm your cough quickly and safely.
  1. Stop Smoking. If you smoke, the best thing you can do for your COPD – and your health – is to stop immediately. ...
  2. Stay Hydrated. ...
  3. Use a humidifier. ...
  4. Try warm tea and honey. ...
  5. Stay upright. ...
  6. Controlled coughing. ...
  7. Speak to your doctor.
15 Dec 2020

What is the oxygen level for COPD? ›

Official answer. Between 88% and 92% oxygen level is considered safe for someone with moderate to severe COPD. Oxygen levels below 88% become dangerous, and you should ring your doctor if it drops below that. If oxygen levels dip to 84% or below, go to the hospital.

What is the most severe stage of COPD? ›

For emphysema, stages are a measure of how well you can breathe. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) is one widely used formula. Stage 4 is the most severe of the four GOLD stages. Doctors use your stages and many other things to evaluate how serious your disease is.

What medication is good for lungs? ›

Bronchodilators: help relax airway muscles to improve breathing for asthma or COPD. Examples include albuterol (ProAir HFA, Ventolin HFA) and salmeterol (Serevent Diskus). They're available in different forms, including tablets, inhalers, nebulizer solution, and syrup.

What medication helps breathing? ›

Theophylline is a bronchodilator, a type of medication that makes it easier to breathe. Brand names include Elixophyllin®, Theobid®, Theo-24®, T-phyl® and Uniphyl®. Theophylline is a long-acting bronchodilator. It provides relief over six to 24 hours.

How can I extend my life with COPD? ›

Here's a look at a few healthy lifestyle tips to live well with COPD.
  1. Quit smoking. ...
  2. Get active. ...
  3. Eat a healthy diet. ...
  4. Stay hydrated. ...
  5. Improve indoor air quality. ...
  6. Get a flu shot. ...
  7. Learn breathing techniques. ...
  8. Get a portable oxygen tank.

How can I increase my lung function if I have COPD? ›

5 Ways to Breathe Easier with COPD
  1. Focus on protecting your overall health. Wash your hands. ...
  2. Use oxygen therapy if you need it. Supplemental oxygen can help you live longer and with fewer COPD symptoms. ...
  3. Follow a healthy COPD diet. ...
  4. Take part in a COPD exercise program. ...
  5. Be mindful about medications.
7 Jan 2022

What are two conditions that most people with COPD have? ›

Emphysema and chronic bronchitis are the two most common conditions that contribute to COPD .

What is the most common cause of death in COPD? ›

In mild to moderate COPD, most deaths are due to cardiovascular disease and lung cancer, but as COPD severity increases, respiratory deaths are increasingly common.

How do you know when the end is near with COPD? ›

Still, signs that you're nearing the end include: Breathlessness even at rest. Cooking, getting dressed, and other daily tasks get more and more difficult. Unplanned weight loss.

How long does it take to get to end stage COPD? ›

End-stage, or stage 4, COPD is the final stage of chronic obstructive pulmonary disease. Most people reach it after years of living with the disease and the lung damage it causes. As a result, your quality of life is low. You'll have frequent exacerbations, or flares -- one of which could be fatal.

Is walking good for COPD? ›

Walking is a safe and effective form of exercise for nearly everyone, including people living with chronic obstructive pulmonary disease (COPD).

Can COPD deteriorate quickly? ›

Exacerbations can happen fast, within a matter of hours or days, according to the American Thoracic Society (ATS).

How much lung capacity can you survive on? ›

Did you know that the maximum amount of air your lungs can hold—your total lung capacity—is about 6 liters? That is about three large soda bottles. Your lungs mature by the time you are about 20-25 years old.

What medication slows the progression of COPD? ›

Corticosteroid treatment, however, appears to reduce the frequency of COPD exacerbations and there is some suggestion that it may also reduce the risk of death in patients with severe COPD.

How do you treat COPD worsening? ›

Hospitalized patients with exacerbations should receive regular doses of short-acting bronchodilators, continuous supplemental oxygen, antibiotics, and systemic corticosteroids. Noninvasive positive pressure ventilation or invasive mechanical ventilation is indicated in patients with worsening acidosis or hypoxemia.

What is considered severe COPD? ›

Stage 3: Severe

By the time you reach stage 3, COPD is considered severe, and your forced expiratory volume is between 30 to 50 percent of your predicted value. You may have trouble catching your breath doing household chores and may not be able to leave your house.

How do people live with severe COPD? ›

Make Lifestyle Changes
  1. Quit smoking. It's the most important thing you can do to improve your life expectancy with COPD.
  2. Avoid secondhand smoke and other things that might irritate your lungs.
  3. Exercise.
  4. Control your weight.
  5. Stay up to date with vaccines, including seasonal flu and pneumonia vaccines.

Can lung damage from COPD be reversed? ›

There is no cure for COPD, and the damaged lung tissue doesn't repair itself. However, there are things you can do to slow the progression of the disease, improve your symptoms, stay out of hospital and live longer. Treatment may include: bronchodilator medication – to open the airways.

Can severe COPD reversed? ›

Although COPD can't be reversed, its symptoms can be treated. Learn how your lifestyle choices can affect your quality of life and your outlook.

Can lungs regenerate from COPD? ›

Several medications with bronchodilating and/or anti-inflammatory effects have been developed and prescribed in clinical practice. However, although many studies have tried to regenerate destroyed alveoli, no therapy has successfully repaired the diseased lungs of patients with COPD.

What can make COPD worse? ›

COPD can get worse from an infection (such as a cold or pneumonia), from being around someone who is smoking, or from air pollution. Other health problems, such as congestive heart failure or a blood clot in the lungs, can make COPD worse. Sometimes no cause can be found.

What makes COPD progress faster? ›

If you continue to smoke, your COPD will progress more quickly compared to someone who doesn't smoke. There are treatments to help COPD, but they won't be as effective if you're still smoking.

What is the first line treatment for COPD exacerbation? ›

ANTIBIOTICS. Antibiotic therapy has been shown to have a small but important effect on clinical recovery and outcome in patients with acute exacerbations of chronic bronchitis and emphysema. Therefore, antibiotic administration should be considered at the beginning of treatment for exacerbations of COPD.

How long do you live with severe COPD? ›

People with severe stage COPD, lose about eight to nine years of life expectancy on average .

Why do you not give oxygen to COPD patients? ›

Supplemental O2 removes a COPD patient's hypoxic (low level of oxygen) respiratory drive causing hypoventilation which causes higher carbon dioxide levels, apnea (pauses in breathing), and ultimately respiratory failure. Another theory is called the Haldane effect.

What is Stage 3 COPD mean? ›

Stage 3 COPD is a severe restriction in the amount of air flowing in and out of your airways. At this stage, it is very likely that your daily activities are being affected by your difficulty in breathing. You may even have been hospitalized one or more times to treat your condition.

How long can a COPD patient live on oxygen? ›

FEV1 is a strong predictor of survival in people with COPD. Those with severe airway obstruction on long-term oxygen therapy have low survival rates (roughly 70% to year one, 50% to year two, and 43% to year three).

Can you love a full life with COPD? ›

Many people are able to maintain a good quality of life while living with chronic obstructive pulmonary disease (COPD). The information below includes ideas for changes you can make to stay active and enjoy your life while managing the disease. When you have COPD, your lungs are weakened.

How does COPD progress to death? ›

Chronic obstructive pulmonary disease (COPD) is a category of conditions that includes emphysema and chronic bronchitis. It is a progressive condition that gets steadily worse. Over time, the body becomes less able to take in enough oxygen. This can ultimately result in death.

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