Steroids and Bronchodilators
Some people with COPD who respond well to oral corticosteroids can be maintained on long-term inhaled steroids.
The use of these drugs is widespread, despite little evidence of efficacy in the treatment of COPD. Inhaled corticosteroids do not slow the decline in lung function. They do, however, decrease the frequency of exacerbations and improve disease-specific and health-related quality of life issues for some people with COPD.
Inhaled corticosteroids have fewer side effects than oral steroids, but they are less effective than oral steroids, even at high doses.
Beta2 Agonists - Bronchodilators
Inhaled beta2-agonist bronchodilators relax and open the breathing passages. They work rapidly, typically within minutes.
Beta2 agonists are primarily used to relieve symptoms of COPD. Inhaled beta2 agonists are the treatment of choice for acute exacerbations of COPD.
Several long-acting beta2 agonists (for example, formoterol, salmeterol [Advair Discus, Advair HFA, Serevent Diskus], indacaterol [Arcapta Neohaler], vilanterol [Anoro, Breo], arformoterol [Brovana], olodaterol [Striverdi, Stiolto]) are available. They may be useful if the patient frequently uses short-acting beta2-bronchodilators or if they experience symptoms at night. It is important to note that in patients with asthma, the FDA has issued a box warning on all long acting beta agonists of sudden cardiac death. This was based on data in one trial (the SMART trial) when these agents where taken alone. When used in combination with other medications, such as inhaled corticosteroids, these cardiac issues have not occurred.
Anticholinergic Agents - Bronchodilators
Maintenance treatment with aerosolized anticholinergic agents (for example, ipratropium [Combivent, DuoNeb, Atrovent HFA, tiotropium [Spiriva], aclidinium [Tudorza], umeclidinium [Incruse]) may be more effective than beta2 agonists for people with COPD, particularly in relieving shortness of breath.
Ipratropium bromide opens the breathing passages and has minimal side effects.
Anticholinergics also dilate airways but through a different receptor than the beta2 agonists. It is administered by a nebulizer, powder, or metered-dose inhaler. The frequency depends on the agent being used. Beta2 agonists can be added as needed. Now combination inhalers are also available, (umeclidinium/vilanterol [Anoro Ellipta] and tiotropium/olodaterol [Stiolto]).
People undergoing exacerbations of COPD respond well to inhaled beta2-agonists and anticholinergic aerosols.
Several options are now available combining steroids and long acting bronchodilators. Several brand names are useful in the treatment of COPD (for example, fluticasone and salmeterol [Advair], budesonide and formoterol inhalation [Symbicort], formoterol and mometasone [Dulera]) with newer agents requiring only once a day dosing (Breo Ellipta).
Methylxanthines, such as theophylline (Elixophyllin, Theo-24, TheoCap, Theochron, Theo-Time, Uniphyl), are a group of medications chemically related to caffeine. They work in COPD by opening the breathing passages. In addition, methylxanthines reduce inflammation, improve respiratory muscle function, and stimulate the brain respiratory center.
Adding theophylline to the combination of bronchodilators can be beneficial, although the response to theophylline may vary among people with COPD. Their use has decreased over the last decade because of the risks of unwanted side effects. Side effects include anxiety, tremors, insomnia, nausea, cardiac arrhythmias, and seizures.