12. Symptom-Based Therapy
In addition to the critically important issue concerning whether a patient with COPD continues to smoke is that concerning whether he or she experiences frequent acute exacerbations. Frequent exacerbations are generally considered to be three or more exacerbations over the preceding three years. In addition to the incremental morbidity and cost, data suggest that lung function decline is also steeper with frequent exacerbations.
Use of inhaled corticosteroids (ICS) may be benefit patients with frequent exacerbations; otherwise, the incremental risk of pneumonia associated with use of ICS, although small, may outweigh their benefit.
Phosphodiesterase-4 (PDE4) inhibitors also appear to benefit patients with chronic bronchitis who experience frequent exacerbations of bronchitis. However, unlike use of ICS, PDE4 inhibitors are suggested only for those with GOLD Stage III or Stage IV disease. Whether there is additional benefit from adding a PDE4 inhibitor to a regimen of ICS and a long-acting beta agonist is unknown.
Both ICS and PDE4 inhibitors benefit current smokers and former smokers; hence, smoking does not preclude benefit from anti-inflammatory therapies. Caution should be used in prescribing the PDE4 inhibitor, Roflumilast, as insomnia, anxiety, and significant weight loss may occur with its use. In GOLD Stages III and IV, depression and low body mass index may limit the pool of candidates appropriate for this therapy.
Macrolides may be useful in reducing the frequency of acute exacerbations, but their use may also increase development of drug-resistant mycobacteria.
Reposted with permission from Decision Support in Medicine, LLC.