Pharmacological strategies to reduce exacerbation risk in COPD: a narrative review.
Identifying patients at risk of exacerbations and managing them appropriately to reduce this risk represents an important clinical challenge. Numerous treatments have been assessed for the prevention of exacerbations and their efficacy may differ by patient phenotype. Given their centrality in the treatment of COPD, there is strong rationale for maximizing bronchodilation as an initial strategy to reduce exacerbation risk irrespective of patient phenotype. Therefore, in patients assessed as frequent exacerbators (>1 exacerbation/year) we propose initial bronchodilator treatment with a long-acting muscarinic antagonist (LAMA)/ long-acting β2-agonist (LABA). For those patients who continue to experience >1 exacerbation/year despite maximal bronchodilation, we advocate treating according to patient phenotype. Based on currently available data on adding inhaled corticosteroids (ICS) to a LABA, ICS might be added to a LABA/LAMA combination in exacerbating patients who have an asthma-COPD overlap syndrome or high blood eosinophil counts, while in exacerbators with chronic bronchitis, consideration should be given to treating with a phosphodiesterase (PDE)-4 inhibitor (roflumilast) or high-dose mucolytic agents. For those patients who experience frequent bacterial exacerbations and/or bronchiectasis, addition of mucolytic agents or a macrolide antibiotic (e.g. azithromycin) should be considered. In all patients at risk of exacerbations, pulmonary rehabilitation should be included as part of a comprehensive management plan.
Pneumology Department, Hospital General Universitari Vall d'Hebron, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain. mmiravitlles@vhebron.net.
Marc
M
Miravitlles
Department of Family and Community Medicine, University of Toronto, 1670 Dufferin Street, Suite 107, Toronto, ON, M6H 3M2, Canada.
Anthony
A
D'Urzo
University of Manchester, Medicines Evaluation Unit, University Hospital of South Manchester Foundation Trust, Southmoor Road, Manchester, M23 9QZ, UK.
Dave
D
Singh
Department of Pneumology, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Simkova 870, Hradec Kralove 1, 500 38, Czech Republic.
Vladimir
V
Koblizek
D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D058666:Adrenergic beta-2 Receptor Agonists / Q000009:adverse effects / Q000627:therapeutic use*; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001993:Bronchodilator Agents / Q000009:adverse effects / Q000627:therapeutic use*; D018450:Disease Progression; D004359:Drug Therapy, Combination; D005100:Expectorants / Q000627:therapeutic use; D006801:Humans; D008168:Lung / Q000187:drug effects* / Q000503:physiopathology; D009079:Mucociliary Clearance / Q000187:drug effects; D018727:Muscarinic Antagonists / Q000009:adverse effects / Q000627:therapeutic use*; D010641:Phenotype; D058988:Phosphodiesterase 4 Inhibitors / Q000627:therapeutic use; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000188:drug therapy* / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome
D000305:Adrenal Cortex Hormones; D058666:Adrenergic beta-2 Receptor Agonists; D000900:Anti-Bacterial Agents; D001993:Bronchodilator Agents; D005100:Expectorants; D018727:Muscarinic Antagonists; D058988:Phosphodiesterase 4 Inhibitors
Bronchitis; Emphysema; Exacerbation; Guidelines; Phenotypes; Prevention; Risk factors; Treatment