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A 58-year-old woman is evaluated during a regular follow-up examination. The patient has moderate chronic obstructive pulmonary disease (COPD); she has dyspnea with moderate activity and a chronic nonproductive cough. Since her previous evaluation 6 months ago she has had three COPD exacerbations requiring systemic corticosteroid and antibiotic therapy, but no hospitalizations. In the previous year she had had one exacerbation and she thinks that her health status has worsened. Her only other medical condition is hypertension. Her medications are tiotropium daily, salmeterol twice daily, albuterol as needed, and amlodipine.
On physical examination, the temperature is 36.0 °C (97.1 °F), pulse rate is 92/min, respiration rate is 20/min, and blood pressure is 135/76 mm Hg; oxygen saturation with the patient breathing ambient air is 96% at rest and 91% after walking 600 feet. Examination of the chest discloses scattered rhonchi bilaterally. Cardiac and lower-extremity examinations are normal. Pulmonary function tests show moderate airflow obstruction; the FEV1 has decreased slightly in the past year.
Which of the following is the most appropriate addition to this patient’s therapy?
A. Oxygen, 2 L/min with activity
B. An inhaled corticosteroid
C. Low-dose oral prednisone
D. Long-term oral antibiotics
Answer: B, An inhaled corticosteroid.
Objective: Treat worsening moderate to severe COPD.
Critique: This patient with moderate chronic obstructive pulmonary disease (COPD) would likely benefit most from the addition of an inhaled corticosteroid to her current regimen. In the past year, two large randomized clinical trials have provided strong evidence for the role of inhaled corticosteroids in moderate to severe COPD. In the Towards a Revolution in COPD Health (TORCH) study, patients with COPD were randomized to salmeterol or fluticasone or a combination of the two. After 3 years of follow-up, there was no difference in mortality, but the combination group had significantly fewer exacerbations. In another trial, Aaron and colleagues compared various treatment regimens for patients with moderate to severe COPD. Treatment groups included tiotropium plus placebo, tiotropium plus salmeterol, and tiotropium plus a fluticasone-salmeterol combination. The exacerbation rate was similar in all three groups, but the tiotropium plus fluticasone-salmeterol group had better lung function, improved quality of life, and fewer COPD-related hospital admissions.
Although oxygen therapy can improve survival and quality of life in hypoxemic patients with COPD, adding oxygen for this patient is not warranted because her oxygen saturation neither at rest nor with activity meet the threshold level required (88%). The use of prednisone for the treatment of chronic COPD should not be confused with its role in acute exacerbations. For this patient with moderate COPD, long-term oral corticosteroid therapy is not recommended because of the significant side effects and increased morbidity associated with its use. Long-term antibiotic therapy has no role in chronic COPD, although antibiotics are recommended in acute exacerbations characterized by increased volume and purulence of secretions. In rare instances, such as in bronchiectasis-related COPD, long-term antibiotic therapy may have a role.
Key Point: In patients with moderate to severe chronic obstructive pulmonary disease with exacerbations, the optimal treatment regimen should include an inhaled anticholinergic agent, a long-acting inhaled ß-agonist, and an inhaled corticosteroid.
All patients with moderate to severe chronic obstructive pulmonary disease should be evaluated for the need for supplemental oxygen.
Aaron SD, Vandemheen KL, Fergusson D, et al; Canadian Thoracic Society/Canadian Respiratory Clinical Research Consortium. Tiotropium in combination
with placebo, salmeterol, or fluticasone-salmeterol for treatment of chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med. 2007;146(8):545-55. [PMID:
Calverley PM, Anderson JA, Celli B, et al; TORCH investigators. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med. 2007;356(8):775-89. [PMID: 17314337]
Qaseem A, Snow V, Shekelle P, et al; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2007;147(9):633-8. [PMID: 17975186]
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