MKSAP Quiz: Managing COPD
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A 70-year-old man with a 7-year history of chronic obstructive pulmonary disease is evaluated for increased fatigue. The patient has daily cough and has had two exacerbations in the past 8 months. He has smoked a pack of cigarettes a day for the past 55 years and has recently stopped smoking. His medications are albuterol as needed, salmeterol, and tiotropium.
On physical examination, vital signs are normal. Breath sounds are decreased, and heart sounds are distant. Oxygen saturation is 93% with the patient breathing ambient air. Spirometry shows an FEV1 of 39% of predicted and an FEV1/FVC ratio of 60%. Chest radiograph shows hyperinflation. The patient is referred for pulmonary rehabilitation.
Which of the following additional therapies would be indicated for this patient?
A. Inhaled corticosteroids
B. Montelukast
C. Oral corticosteroids
D. Theophylline
MKSAP Answer and Critique
The correct answer is A) Inhaled corticosteroids. This item is available to online to MKSAP 15 subscribers as item 71 in Pulmonary and Critical Care Medicine.
This patient has severe (GOLD stage III) chronic obstructive pulmonary disease (COPD) defined as FEV1/FVC <70% and FEV1 30% to 50% of predicted with or without chronic symptoms (cough, sputum production). Treatment for this patient includes support for his smoking cessation, short-acting bronchodilators as needed, and regular treatment with one or more long-acting bronchodilators, as well as an inhaled corticosteroid, along with pulmonary rehabilitation.
Oral corticosteroids are not recommended for regular use in a long-term maintenance program because there has been no consistent evidence of efficacy or superiority compared with other agents that have fewer adverse effects. Low-dose theophylline reduces exacerbation in patients with COPD but does not increase post-bronchodilator lung function significantly. High-dose theophylline is an effective bronchodilator but due to its potential toxicity inhaled bronchodilators are again preferred. Leukotriene modifiers, such as montelukast, are not recommended in COPD. Many studies have evaluated leukotriene modifiers in COPD, but the improvement in lung function and symptoms with these agents is modest at best.
Two recent long-term studies of more than 11,000 patients have evaluated treatment for patients with GOLD stages II to IV. The TORCH study and the UPLIFT study showed that in patients with COPD, combination therapy with bronchodilators and an inhaled corticosteroid improved quality of life and pulmonary function without significant adverse effects. Patients enrolled in pulmonary rehabilitation programs benefit with respect to both exercise tolerance and symptoms of dyspnea and fatigue. The minimum length of an effective rehabilitation program is 2 months, but the longer the program continues, the more effective the results are.
Key Point
- Treatment of GOLD stage III chronic obstructive pulmonary disease includes short-acting bronchodilators as needed and regular treatment with one or more long-acting bronchodilators with an inhaled corticosteroid and pulmonary rehabilitation.