Discuss pharmacotherapy in conjunction with examination findings, symptoms, and test results to determine the need to modify dosage or agent and to assess treatment adherence and inhaler technique.

Comorbidity is often substantial in COPD patients, and such conditions as heart disease, diabetes, and depression may complicate and be complicated by the disorder. An integrated approach to total management is vital in primary care.

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Drug treatment

The immediate goals of pharmacotherapy are to improve symptoms and quality of life and reduce exacerbations. For mild COPD (FEV1 ≥80% predicted), a short-acting bronchodilator is usually sufficient.

When COPD is moderate (50% ≤FEV<80% predicted) and sustained bronchodilation is needed, a long-acting agent should be added. Regular inhaled glucocorticosteroids should be considered when disease is severe or worse (FEV1 <50% predicted). “More and more data strongly show that patients may benefit from these drugs earlier in the disease if they have been having frequent exacerbations,” Dr. Azueto says.

All commonly used bronchodilators (b2-agonists, anticholinergics, and methylxanthines) have been shown to increase exercise capacity without improving lung function. The choice should be based on availability, response, and cost. Combining agents of different classes may achieve superior bronchodilation with fewer adverse effects but do so at increased cost.

There is limited evidence that inhaled glucocorticosteroids, long-acting bronchodilators, or a combination of the two can reduce the rate of lung-function decline. The GOLD update cites findings to this effect from a large randomized controlled trial.

Keep in mind that patients taking inhaled steroids, with or without a long-acting bronchodilator, are at increased risk of pneumonia. “Patients should see their provider right away if they have any respiratory symptoms,” says Dr. Anzueto.

The GOLD guidelines recommend yearly influenza vaccination for all COPD patients. Those older than age 65 years or with FEV1<40% predicted should have pneumococcal polysaccharide vaccine as well.

There is insufficient evidence to recommend widespread use of other medications (e.g., mucolytics, antioxidants, immunoregulators). Antitussives and vasodilators are contraindicated.

Nonpharmacologic treatment

Addressing COPD risk factors will slow progression and reduce exacerbations. First and foremost is avoiding tobacco smoke: all patients should minimize passive exposure, and those who still smoke should be actively helped to quit (possibly with pharmacologic support). Patients should avoid exposure to toxins and irritant dusts as well.

The GOLD guidelines recommend that patients refrain from vigorous outdoor exercise when pollution levels are high; those with severe disease should consider staying indoors as much as possible when air quality is poor.