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Chronic obstructive pulmonary disease (COPD) is a common problem among patients presenting to primary care. This condition has multiple individual and combined treatment regimens. The goals of treatment are to improve quality of life, exercise tolerance, sleep quality, and survival; and to reduce dyspnea, nocturnal symptoms, exacerbations, use of rescue medications, and hospitalizations. All patients benefit from bronchodilator medications as needed. Long-acting inhaled anticholinergics are probably more beneficial than short-acting formulations. Use of inhaled corticosteroids might benefit patients with mild COPD who have an inflammatory component or significant reversibility on spirometry. Patients with moderate to severe disease benefit from the use of long-acting inhaled anticholinergics, inhaled corticosteroids, and possibly a long-acting beta2 agonist or mucolytics. For rescue therapy, short-acting beta2 agonists or combination anticholinergics with a short-acting beta2 agonist should be used. Inhaled corticosteroids should be considered before initiating a long-acting beta2 agonist. Caution should be used if a long-acting beta2 agonist is discontinued before initiation of an inhaled corticosteroid because this may precipitate exacerbations. Evidence to support the use of mucolytics, oral theophylline, and oral corticosteroids is limited. Patients with severe hypoxemia (i.e., arterial oxygen pressure less than 55 mm Hg or oxygen saturation less than 88 percent) should be given continuous oxygen. (Am Fam Physician 2007;76:1141-8, 1151-2. Copyright © 2007 American Academy of Family Physicians.)
Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and affects 20 percent of adults.1,2 It is the 19th most common diagnosis made during visits to family physicians.3 Exposure to tobacco smoke is associated with an increased lifetime risk of developing COPD,4 and preexisting asthma is associated with a 17-fold increase in that risk.5
The goals of treatment for COPD are to improve quality of life, exercise tolerance, sleep quality, and survival; and to reduce dyspnea, nocturnal symptoms, exacerbations, use of rescue medications, and hospitalizations. There are multiple individual and combined treatment regimens, with options including anticholinergics, beta2 agonists, smoking cessation, and steroids. This article reviews the recommendations and evidence for the pharmacologic management of stable COPD, highlighting the effect of medications on patient-oriented outcomes, such as mortality, symptoms, and hospitalization, where data exist. Information about the most commonly used medications is summarized in Table 1.6-15
Anticholinergics (Inhaled)
Inhaled...