Pharmacist Disease State Guides
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      Chronic Obstructive Pulmonary Disease (COPD)

      Disease State Overview

      Chronic obstructive pulmonary disease (COPD) is characterized by persistent respiratory symptoms and airflow limitation. COPD can include dyspnea, cough, and/or sputum production. The main risk factor for COPD is tobacco smoking, although other environmental factors can contribute. COPD is a chronic condition which can include periods of acute worsening or exacerbations. Chronic lung inflammation can lead to irreversible structural changes within the lungs, diminishing the ability for airways to remain open. 

      Risk of Condition 

      Uncontrolled COPD can lead to exacerbations, airway damage, decline in lung function, and COPD-related death. People with COPD are at an increased risk of respiratory infections, heart problems, lung cancer, and pulmonary hypertension. 

      Medication 

      Role of Medication 

      COPD treatment goals include slowing disease progression, reducing symptoms, reducing exacerbations, improving exercise tolerance, and enhancing quality of life. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend an individualized treatment approach based on symptoms and exacerbation risk. Choice of therapy should be based on multiple factors including the patient’s willingness and ability to use the medication, medication side effect profile, insurance coverage, age, comorbid conditions, and concurrent medications. 

       

      GOLD Guidelines for COPD Treatment - Exacerbation History and Group/Treatment

      • > 2 moderate exacerbations or > 1 leading to hospitalization 
        • Group E

          • LAMA & LAMA* 

          • Consider LABA + LAMA + ICS* (eosinophil count ≥300 cells/µL) 
      • 0 or 1 moderate exacerbation (not leading to hospital admission) 
        • Group A
          • Bronchodilator (short or long-acting) 
        • Group B
          • LABA & LAMA* 
      • Evaluation of symptoms 
        • mMRC = 0-1, CAT < 10 
        • mMRC > 2, CAT > 10 

      *single inhaler therapy may be more convenient and effective than multiple inhalers  

      Abbreviations used: LAMA – long-acting muscarinic antagonist, LABA – long-acting beta2 agonist, ICS – inhaled corticosteroid, mMRC – modified Medical Research Council dyspnea questionnaire, CAT – COPD Assessment Test 

      Common COPD Medications 

      Short-Acting Medications

      • Drug Class: SABA 
        • Drug Names:
          • Albuterol (ProAir, Proventil, Ventolin)  - Inhaler Type: MDI, DPI, Nebulizer 
          • Levalbuterol (Xopenex) - Inhaler Type: MDI, Nebulizer
      • Drug Class: SAMA
        • Drug Names: 
          • Ipratropium (Atrovent)  - Inhaler Type: MDI
      • Drug Class: SABA + SAMA
        • Drug Names:
          • Ipratropium and Albuterol (Combivent Respimat+, DuoNeb*) - Inhaler Type: SMI & Nebulizer

      Long-Acting Medications 

      • Drug Class: LABA
        • Drug Names:
          • Arformoterol (Brovana)  - Inhaler Type: Nebulizer
          • Formoterol (Perforomist) - Inhaler Type: Nebulizer
          • Olodaterol (Striverdi Respimat) - Inhaler Type: SMI
          • Salmeterol (Serevent Diskus) - Inhaler Type: DPI
      • Drug Class: LAMA
        • Drug Names: 
          • Umeclidinium (Incruse) - Inhaler Type: DPI
          • Glycopyrrolate (Lonhala)  - Inhaler Type: DPI
          • Tiotropium (Spiriva Respimat, Spiriva HandiHaler) - Inhaler Type: SMI, DPI
          • Aclidinium (Tudorza Pressair)  - Inhaler Type: DPI
          • Revefenacin (Yupelri) - Inhaler Type: Nebulizer
      • Drug Class: LABA + LAMA
        • Drug Names: 
          • Glycopyrrolate and Formoterol (Bevespi Aerosphere) - Inhaler Type: MDI
          • Tiotropium and Olodaterol (Stiolto Respimat) - Inhaler Type: SMI
          • Umeclidinium and Vilanterol (Anoro Ellipta) - Inhaler Type: DPI
          • Aclidinium and Formoterol (Duaklir Pressair) - Inhaler Type: DPI
      • Drug Class: ICS + LABA
        • Drug Names: 
          • Budesonide and Formoterol (Symbicort) - Inhaler Type: MDI
          • Fluticasone and Salmeterol (Advair Diskus*, Advair HFA+, AirDuo Digihaler*, AirDuo RespiClick*, Wixela Inhub*) - Inhaler Type: MDI, DPI
          • Mometasone and Formoterol (Dulera) - Inhaler Type: MDI
          • Fluticasone and Vilanterol (Breo Ellipta) - Inhaler Type: DPI
      • Drug Class: LABA + LAMA + ICS
        • Drug Names: 
          • Budesonide, Glycopyrrolate, and Formoterol (Breztri Aerosphere) - Inhaler Type: MDI
          • Fluticasone, Umeclidinium, and Vilanterol (Trelegy Ellipta) - Inhaler Type: DPI
          • Roflumilast (Daliresp) - Inhaler Type: NA – Oral Medication  

      Abbreviations used: SAMA – short-acting muscarinic antagonist, SABA – short-acting beta2 agonist, LAMA – long-acting muscarinic antagonist, LABA – long-acting beta2 agonist, ICS – inhaled corticosteroid, PDE-4 – phosphodiesterase-4  

      Adherence 

      Using short-acting and long-acting medications correctly is essential for COPD symptom control. Discuss the differences and when to use each type of medication. Discuss barriers to adherence and provide appropriate solutions. You may use the DRAW tool within the Resources section of our Outcomes platform.  

      • Short-acting medications should be used on an as-needed basis; assess for overuse. 
      • Long-acting medications should be used on a regular basis as prescribed; assess for underuse.  

      Administration 

      On average, more than two-thirds of patients make at least one error in using an inhalation device, according to GOLD guidelines. Pharmacists play a key role in the training and education of inhaler use, priming, technique and cleaning for patients with COPD.  

      • Inhaler technique (refer to package insert) 
        • Ensure the patient knows how to correctly administer the medication. 
      • Inhaler priming (refer to package insert) 
        • Most short-acting inhalers should be primed when not used within the last 2 weeks. 
        • Ensure the patient knows when to prime their inhaler, if applicable. 
      • Inhaler cleaning (refer to package insert) 
        • Ensure the patient knows how to correctly clean the inhaler. 
      • Use of nebulizer, spacer, or mask devices, if applicable 
        • Keep in mind not all inhaler types work with these devices  
      • Advise patient to rinse mouth and spit after using ICS medications. 

      Monitoring 

      Monitoring for COPD disease progression includes completing spirometry measurements, periodic assessment of symptoms, tracking of exacerbations (including hospitalizations) and evaluation of smoking status. 

      Patients should be educated to monitor and report increased or worsened symptoms including: 

      • Cough
      • Sputum production 
      • Shortness of breath 
      • Fatigue 
      • Limitations in activity 
      • Sleep disturbance 

      Lifestyle Education 

      Lifestyle modifications are important in the management of COPD. Discussion points may include: 

      • Educating the patient on important vaccinations for people with COPD including influenza and pneumococcal vaccines.  
      • In patients who smoke, recommend smoking cessation and provide counseling on appropriate options and resources 

       

       

      Resources 

      1. 1. 2024 Gold Report - Global Initiative for Chronic Obstructive Lung Disease. Global Initiative for Chronic Obstructive Lung Disease (GOLD). https://goldcopd.org/2024-gold-report/.