• 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

Pathophysiology

  • 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.

Diagnosis

  • Spirometry à post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation.

Treatment

Non-pharmacologic Treatment

  • 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.

Bronchodilator Therapy

  • 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

  • Inhaled corticosteroids
    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.
  • Oral corticosteroids
    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.  

Miscellaneous

  • Alpha 1 antitrypsin augmentation therapy
    Iv augmentation therapy may slow down the progression of emphysema.
  • Antitussives
    No conclusive benefit
  • Antibiotics:
    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

  • Benralizumab
  • Mepolizumab
  • Lebrikizumab

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).

Eosinophilic 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

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