- COPD is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.
- Terms emphysema and chronic bronchitis are no more included in the definition.
- Global Prevalence: 11.7%
- Deaths – 3 million annually. Expected to rise to 4.5 million by 2030.
- Second largest non-communicable cause of death in India
- The fourth leading cause of years of life lost in Empowered Action Group (EAG)
- DALYs due to COPD increased 36.3% from 1990 to 2016 and it became the second leading cause of DALYs in India
- inflammation of the respiratory tract with a pattern that differs from that of asthma.
- In COPD, there is a predominance of neutrophils, macrophages, cytotoxic T lymphocytes (Tc1 cells), and T helper-17 (Th17) cells.
- The inflammation predominantly affects small airways, resulting in progressive small-airway narrowing and fibrosis (chronic obstructive bronchiolitis) and
- destruction of the lung parenchyma with the destruction of the alveolar walls (emphysema)
- These pathological changes result in airway closure on expiration, leading to air trapping and hyperinflation, particularly on exercise (dynamic hyperinflation).
- This accounts for shortness of breath on exertion and exercises limitations that are characteristic symptoms of COPD.
- Bronchodilators reduce air trapping by dilating peripheral airways and are the mainstay of treatment in COPD.
- In contrast to asthma, the airflow obstruction of COPD tends to be progressive.
- In contrast to asthma, the inflammation in patients with COPD is largely corticosteroid resistant, and there are currently no effective anti-inflammatory treatments.
- Spirometry à post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation.
- Symptom control and palliative care
- Oxygen therapy and ventilatory support
- Surgical interventions
- Vaccination à
- Influenza vaccination can reduce serious illness (such as lower respiratory tract infections requiring hospitalization)24 and death in COPD patients.
- Pneumococcal vaccinations, PCV13, and PPSV23 are recommended for all patients ≥ 65 years of age
Smoking cessation à long-term quit success rates of up to 25% can be achieved.
- Inhaled bronchodilators are central to symptom management and given or a regular basis to prevent or reduce symptoms
- Regular and as-needed use of SABA or SAMA improves FEV1 and symptoms.
- Combinations of SABA and SAMA are superior to either medication alone in improving FEV1 and symptoms
- LABAs and LAMAs significantly improve lung function, dyspnea, health status and reduce exacerbation rates
- LABA + LAMA increases FEV1 and reduces symptoms compared to monotherapy.
- Theophylline exerts a very small bronchodilator effect in stable COPD and that is associated with modest symptomatic benefits.
Anti Inflammatory drugs
An ICS + LABA more effective than monotherapy.
Regular treatment with ICS increases the chances of pneumonia.
- Triple inhaled therapy of ICS/LAMA/LABA improves lung function, symptoms, and health status.
Long term use of oral glucocorticoids has numerous side effects with no evidence of benefits.
- Long term ICS monotherapy is not recommended.
- Longterm ICS + LABA may be considered in patients with a history of exacerbations
- Long term oral corticosteroids not recommended.
- Consider PDE4 inhibitors in patients with exacerbations despite LABA/ICS or LAMA/LABA/ICS
- In former smokers with exacerbations, macrolides can be considered.
- Statin therapy is not recommended for the prevention of exacerbations.
- Antioxidant mucolytics are recommended only in selected patients.
1 antitrypsin augmentation therapy
Iv augmentation therapy may slow down the progression of emphysema.
No conclusive benefit
Long term azithromycin therapy reduces exacerbations over one year.
It can lead to bacterial resistance and impaired hearing tests.
Recently Approved Drugs/ FDCs for COPD
Drugs in pipeline
Asthma-COPD overlap syndrome (ACOS)
asthma-COPD overlap captures the subset of patients with airways disease who have features of both asthma and chronic obstructive pulmonary disease (COPD).
- Inhaled corticosteroids + LABA (mixed evidence)
- Anti Ig-E therapies
- Anti IL-5/ IL-5Ra therapies
- Anti IL-13/ IL-4Ra therapies
Neutrophilic Asthma: Macrolides
Pauci-granulocytic ACOS: LAMA