Dr. Anzueto: In order to determine the medication that we want to use, we should evaluate the patients based on the different risks and the combination of disease severity, symptoms, and [the risk of] having future events, such as COPD exacerbation or hospital admissions. The GOLD (the Global Initiative for COPD) has recommended that we should stratify our patients into four groups based on the complexity of the disease: Patients in Group A will be individuals with [a] low risk for exacerbation and not very symptomatic; patients in Group B have few exacerbations, but are more symptomatic; while Group C and D are patients who have more severity of the disease, are having frequent exacerbations and/or hospitalizations, and more severe symptoms.1
So once you have evaluated your patients and identified in which group they fall, then we can make decisions about therapy. For example, patients who have symptoms related to their COPD [Groups B to D], the first choice of therapy is the use of long-acting bronchodilators, either a long-acting muscarinic antagonist or a long-acting beta2 agonist (LAMAs or LABAs). Then therapy will be escalated based on the frequency of exacerbations or symptoms. Our goal will be to improve patients' lung function and symptoms the best we can, and we may be able to achieve this [even] in patients with milder disease. For example, even though the recommended first choice of therapy for Group B patients, according to the current GOLD recommendations, is regular treatment with a long-acting anticholinergic or long-acting beta2 agonist, they also suggest considering regular treatment with [a] combination of these bronchodilators. The ultimate objective is to improve patient symptoms as much as possible.
In patients who remain symptomatic despite having this combination of therapy, we can also consider the use of inhaled corticosteroids or eventually even theophylline. Theophylline is usually indicated in patients with very severe disease who are already receiving combination therapy with an inhaled corticosteroid and long-acting bronchodilators. This medication is used at low doses, 100 to 200 mg/d, and its main effect is enhancing the steroid receptor activity.
Other medications that we have available in patients who have more severe disease are the phosphodiesterase-4 [PDE-4] inhibitors. These medications decrease inflammation and may promote airway smooth muscle relaxation. Roflumilast is an oral PDE-4 inhibitor that is approved for use in patients with severe COPD who have a history of chronic bronchitis and exacerbations and has been shown to significantly reduce the frequency of exacerbations.2-5
When patients are having frequent exacerbations, and they are already on long-acting bronchodilators, the GOLD initiative suggests to add inhaled corticosteroids. If they have chronic bronchitis, you can also use roflumilast.
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