COPD Pharmacology

Chronic Obstructive Pulmonary Disorder (COPD) is a preventable chronic inflammatory pulmonary illness that obstructs the airflow in the lungs. For the majority of the cases, COPD presents with three main symptoms: A chronic cough, sputum production and dyspnoea. And roughly 80-90% of the patients suffering from COPD would have been or still are tobacco smokers.

The management of COPD takes a wide approach to slow down the disease progression as well as treat the presenting symptoms. Treatment typically includes smoking cessation, supplemental oxygen therapy and medication. In advanced cases, some patients would be good candidates for surgical interventions while others might require palliative care.

In these notes, we’ll be going over COPD Pharmacology, including Bronchodilators, Corticosteroids and Combined Therapy.

But before getting into that, make sure that you’ve understood the:

1. Anatomy & Physiology of the Respiratory System

2. The Pathophysiology of COPD

3. The Nursing Assessment for Patients with COPD

4. Risk reduction and Oxygen Therapy in COPD

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COPD Pharmacology: Bronchodilators

You’ll probably notice that bronchodilators are commonly used in a lot in the medical management of respiratory diseases, yet their use does not ‘cure’ the patient. In reality, the goal of bronchodilators is to suppress the symptoms of respiratory disease and allow the patient to breathe and live more comfortably.

Bronchodilators target the smooth muscle tone found in the airway allowing it to relax and minimise the obstruction, (ie. The same airways that are irritated and inflamed from COPD). This action increases the oxygen delivery to the lungs and improves alveolar ventilation allowing the lungs to empty completely with each breath.

Depending on the patient’s situation, they will receive either:

1. Short-acting bronchodilators: Prescribed during an exacerbation of COPD and acute phase, or as preventive therapy before a strenuous exercise.

2. Long-acting bronchodilators: Prescribed to control the long term symptoms of COPD and improve the effectiveness of Corticosteroids (which as you’ll see later are another class of drugs prescribed for the management of COPD).

Three main classes of Bronchodilators

The two most commonly used bronchodilators are Beta2 Agonists and Anticholinergic agents, both of which can be found in a short-acting and long-acting form. And the third common class of bronchodilators is Xanthines, which can only be found in a long-acting form. These medications can either be inhaled through pressurized metered-dose inhales, dry-powder inhalers or small-volume nebulizer. Or can be administered orally through a pill or liquid form.

The following tables summarise the three classes of bronchodilators:

Table 1: Short-Acting Bronchodilators

Class	Beta 2- Agonists
Generic Example	Salbutamol
Trade Name	Ventolin
Side Effects	Palpitations Tremor Headache
Warning (the medication might trigger or aggravate..)	Paradoxical Bronchospasm Hypersensitivity Cardiovascular effects Hypokalemia
Drug Interactions	Beta Blockers Digoxin Non-Potassium Sparing Diuretics
References	​https://www.rxlist.com/ventolin-hfa-drug.htm#warnings

Table 2: Long-Acting Bronchodilators

Class	Beta 2-Agonists	Anticholinergics	​Xanthines
Generic Example	Salmeterol Xinafoate	Tiotropium	Theophylline
Trade Name	Serevent	Spiriva	Aminophylline/ Theo 24
Side effects	Throat Irritation Musculoskeletal Pain Hypertension /Hypotension Tachycardia	URTI Dry mouth Sinus infection	Insomnia Irritability Increased urination
Warnings (the medication might trigger or aggravate..)	Paradoxical Bronchospasm Cardiovascular effects Diabetes Mellitus Ketoacidosis Hypokalemia	Paradoxical Bronchospasm Glaucoma Renal Impairment Urine Retention Not suitable for patients with lactose or milk proteins allergy	Has various drug interactions Requires close monitoring of the Serum Theophylline Concentrations in the blood especially when changing doses
Drug Interactions	​Cytochrome P450-3A4-Inhibitors Tricyclic Antidepressants Beta-Blockers Non-Potassium Sparing Diuretics	Sympathomimetics Methylxanthines Steroids	Adenosine Benzodiazepines
References	https://www.rxlist.com/serevent-diskus-drug.htm#side_effects	https://www.rxlist.com/consumer_tiotropium_spiriva_respimat/drugs-condition.htm	https://www.rxlist.com/consumer_theophylline_elixophyllin_uniphyl/drugs-condition.htm

COPD Pharmacology: Corticosteroids

Similarly to Bronchodilators, Corticosteroids do not cure COPD but they treat the secondary symptoms that arise from COPD and facilitate better oxygen flow. Moreover, long-term use of corticosteroids is not recommended because the side effects would outweigh the benefits. Researchers have shown that when used for a long period, corticosteroids can cause myopathy, muscle weakness and in advanced disease they could lead to respiratory failure. Typically corticosteroids are administered as inhalers or oral medication.

Table 3: Oral vs Inhaled Corticosteroids

Administered Route	Oral	Inhalation
Examples of Generic Drug	Prednisone Hydrocortisone Prednisolone Methylprednisolone Dexamethasone	Beclamethasone Dipropionate Budesonide Ciclesonide Flunisolide Fluticasone Propionate Mometasone
Side Effects	Acne Thinning skin Weight gain Insomnia	Sore throat Bad tase in mouth Epistaxis Stuffy nose
Warnings	Cardio-Renal Effects Endocrine complications Thyroid function affects the metabolic clearance of oral corticosteroids More susceptible to infections Ophtalmic complications	Adrenal insufficiency Paradoxical Bronchospasm More susceptible to infections Dental and oral damage
Drug Interactions	​Live vaccines Amphotericin B injection Potassium-Depleting Agents Antibiotics Antidiabetics	CYP3A4 Inhibitors Long-term Ketoconazole
References	https://www.rxlist.com/prednisone-drug.htm#interactions	https://www.rxlist.com/pulmicort-turbuhaler-drug.htm#interactions

COPD Pharmacology: Combined Therapy

In cases where COPD is rather advanced, the patient might be prescribed a combination of drugs, as research has shown that combination therapy is associated with a more effective outcome. The most two common combinations are:

1. An inhaled Anticholinergic agent and Beta2 Agonists specifically Ipratropium and Albuterol via a metered-dose inhaler. This method is often used to treat bronchospasm in COPD as it alleviates the symptoms of dyspnoea and wheezing.

2. An inhaled Corticosteroid and Long-Acting Beta2 Agonists. Patients who received this approach recorded an improvement in their quality of life, a decrease in the frequency of exacerbations and an increase in their lung function.

Table 4: Combined Therapy

Combination	Anticholinergic Agent & Beta2 Agonist	Corticosteroid & Long-Acting Beta2 Agonist
Generic Names	Ipratropium Bromide & Albuterol Sulfate	Budesonide & Formoterol Fumarate Dihydrate
Brand NAmes	Duoneb	Symbicort
Side Effects	Voice alterations Headache Chest pain	Throat irritation Oral Candida
Warnings	​More prone to respiratory infections Paradoxical Bronchospasm Cardiovascular Effects Diabetes Mellitus Ketoacidosis	More prone to respiratory infections Paradoxical Bronchospasm Cardiovascular Effects Glaucome and Cataracts Hyper/Hypoglyacemia Immunosuppression Hyper corticism and Adrenal Suppression
Drug Interactions	Beta- receptor blocking agents Diuretics Monoamine oxidase inhibitors Tricyclic Antidepressants	Cytochrome P450 3A4 Inhibitors
References	https://www.rxlist.com/duoneb-drug.htm#interactions	https://www.rxlist.com/symbicort-drug.htm#warnings

COPD Pharmacology: Mucolytic Agents

Mucolytic Agents are a class of medications that slow down the production of mucus and make it’s consistency thinner. They also promote mucociliary clearance and help the individual to expectorate more easily. Because of these properties, Mucolytic Agents are used to treat the symptoms of patients with a more severe COPD and those that have frequent and prolonged exacerbations. The two most common Mucolytic agents are Acetylcysteine most commonly found as a nebulizer and Carbocisteine most commonly prescribed as a syrup. Given that both of them attack the secretions, it is important to monitor the patient’s airway and ensure that they can cough up the secretions otherwise mechanical suctioning might be required.

That’s pretty much it for the Pharmacological Treatment of COPD! If you have any questions send them over on my Instagram @Nurse.Miriana