COPD Pharmacology

Updated: May 26

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

 

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


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


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


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


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 


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