Dr. Lijo John
Dr. Lijo John is a community pharmacist with 9 years of experience and graduated from Rutgers University in 2012. He has extensive experience serving patients with a focus in geriatric medicine, diabetes management, and preventative medicine such as immunizations and lifestyle modification counselling. Dr. John also enjoys writing and presenting on complex medical topics aimed at the general population to drive positive behavioral change in topics such as vaccine hesitancy and smoking cessation.
Overview of “Condition”
Chronic obstructive pulmonary disease (COPD) is a progressive and irreversible disease that is primarily caused by cigarette smoking as well as exposure to other toxins. It is the fourth leading cause of death in the United States. The only way to slow the progression of COPD is to stop smoking and avoid other toxins known to worsen the condition. 1
How Has Treatment Developed Over Time?
The current non-pharmacologic treatment paradigm includes inhaled pulmonary rehabilitation, which is exercise training to reduce symptoms of dyspnea and fatigue. If a patient’s COPD has progressed to the point of having reduced oxygen levels in the blood even at rest, they may benefit from supplemental oxygen therapy. This has been shown to reduce mortality. COPD patients are strongly advised to stay up to date with recommended vaccines as this can reduce the likelihood of respiratory infections that can lead to COPD exacerbations. Recommended vaccinations include the annual influenza vaccine, as well as the two pneumonia vaccines, PPSV23 and PCV13. 2
What is the Current Standard of Care?
Pharmacologic options for COPD are used to alleviate symptoms and do not improve survival rates like smoking cessation and oxygen therapy do. Short-acting bronchodilators are used as initial therapy and fall under two categories, short-acting beta agonists (SABA) and short-acting anti-muscarinic agents. They can be used for patients with occasional symptoms in addition to being used as rescue inhalers. Patients with more persistent symptoms can be treated with long-acting bronchodilators which include long-acting beta agonists (LABA) and/or long-acting muscarinic agents (LAMA). These agents provide significant improvement in symptoms, lung function as well as decreasing exacerbations, at the cost of increasing adverse effects. In patients with acute exacerbations of COPD, treatment includes increasing dose of bronchodilators and a course of systemic corticosteroids. Antibiotics are recommended in an acute exacerbation episode if the patient exhibits severe symptoms.2
What Are Some Newer Treatments?
In patients whose symptoms are not controlled with a single long-acting bronchodilator, a combination of LABA and LAMA is recommended. In recent years, several combination inhalers have been approved by the FDA to improve patient adherence and convenience, such as Anoro Ellipta3 (umeclidinium and vilanterol) and Stiolto Respimat4 (tiotropium and olodaterol). In those patients whose symptoms still persist and require an inhaled corticosteroid, Trelegy combines the LABA and LAMA with an inhaled corticosteroid (umeclidinium, vilanterol, and fluticasone furoate)5. Daliresp (roflumilast) is a newer option for patients who are already on inhalers and suffer 2 flare-ups within the last 12 months6. This oral medication can reduce inflammation in the lungs and airways. In advanced emphysema, endobranchial valve (EBV) implantation can also provide improvement in symptoms and lung function6. The long term role of this device is still being studied.
What New Clinical Trials Are Currently Being Ran?
There are new molecules being studied for this disease including new combination inhalers7, dual inhaler with a new mechanism of action (Ensifentrine)8, and an existing drug with a novel delivery system9. Research is also being done to improve the diagnostics of this disease and to enable earlier detection of airway inflammation10. COPD is currently an irreversible disease, and there are attempts to find new molecules that will help cure or reverse the disease. However, these are still in the investigative stage and a long way from becoming part of the standard of care.
- Global Initiative for Chronic Obstructive Lung Disease. Accessed July 27, 2020. https://goldcopd.org/
- DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic Approach, 10e. McGraw-Hill; Accessed February 23, 2021. https://accesspharmacy.mhmedical.com/content.aspx?bookid=1861§ionid=146028752
- Anoro Ellipta. Package Insert. GlaxoSmithKline; 2013. https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/203975s000lbl.pdf
- Stiolto Respimat. Package Insert. Boehringer Ingelheim; 2016. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/206756s006lbl.pdf
- Trelegy Ellipta. Package Insert. GlaxoSmithKline; 2017.
- Package Insert. Forest Pharmaceuticals; 2013.
- Labarca G, Uribe JP, Pacheco C, et al. Bronchoscopic Lung Volume Reduction with Endobronchial Zephyr Valves for Severe Emphysema: A Systematic Review and Meta-Analysis. Respiration. 2019;98(3):268-278. doi:10.1159/000499508
- Dose ranging study of RPL554 in COPD patients. https://clinicaltrials.gov/ct2/show/study/NCT03443414?term=RPL554&recrs=e&rslt=With&draw=2&rank=4
- Donohue JF, Goodin T, Tosiello R, Wheeler A. Dose selection for glycopyrrolate/eFlow(®) phase III clinical studies: results from GOLDEN (Glycopyrrolate for Obstructive Lung Disease via Electronic Nebulizer) phase II dose-finding studies. Respir Res. 2017 Dec 4;18(1):202. doi: 10.1186/s12931-017-0681-z.
- Vasilescu DM, Martinez FJ, Marchetti N, et al. Noninvasive Imaging Biomarker Identifies Small Airway Damage in Severe Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2019;200(5):575-581. doi:10.1164/rccm.201811-2083OC