New COPD guidelines tout bronchodilators and antibiotics

Recent guidelines suggest the use of long-term macrolide antibiotic therapy and rapid-acting bronchodilators for COPD patients, while inhaled corticosteroids (ICS) should be used more sparingly, according to a new study.

After reviewing several new guidelines in COPD, the researchers found that ICS should only be used in conjunction with long-acting bronchodilator therapy to reduce exacerbations of disease and may be utilized in individuals with moderate to very severe disease.

“The availability of newer classes and types of inhaled bronchodilators, including long-acting beta agonists (LABAs)  and long-acting muscarinic antagonists (LAMAs); emerging data on comparative efficacy of various bronchodilator regimens versus ICS combinations; and data suggesting that stepwise and gradual withdrawal of ICS therapy will not worsen exacerbations of disease, have prompted reconsideration of the role of ICS therapy to prevent exacerbations of disease,” wrote Dixit and colleagues.

There are numerous, well-established risks associated with chronic systemic corticosteroid therapy, including hyperglycemia, hypertension, weight gain, mood disturbances, skeletal adverse effects and insomnia. Plus, “long-term use (beyond 30 days) has not been demonstrated to have a greater effect on exacerbation reduction,” they wrote.

However, there are still two major therapies that can effectively treat COPD. Long-acting bronchodilators are generally preferred to manage chronic bronchoconstriction in COPD. “Both LABAs and LAMAs, when compared with placebo, are likely to reduce moderate-to-severe acute exacerbations of disease,” the researchers wrote.

In addition, the macrolide antibiotic azithromycin may reduce inflammation and modulate the immune response in the upper airways, the researchers said. “Current guidelines suggest use of long-term macrolide therapy for patients with one or more moderate-to-severe exacerbations of disease in the previous year despite optimization of inhaler use, although clinicians must weigh the risks of QTc prolongation (including history of cardiovascular disease or dysrhythmia, concomitant medication use, and presence of electrolyte disturbances), emergence of bacterial resistance, and patient cost when considering this type of treatment.”

Several clinical trials have evaluated different dosing and administration strategies for azithromycin in reducing exacerbations of COPD, the authors noted, including one study in which investigators found azithromycin use to be associated with a significant reduction in exacerbations of COPD, from 1.83 to 1.48 acute exacerbations per patient-year.