Treatment of patients with frequent COPD exacerbations despite inhaled therapies

COPD: chronic obstructive pulmonary disease; ICS: inhaled glucocorticoid (aka inhaled corticosteroid); LABA: long-acting beta-agonist; LAMA: long-acting muscarinic antagonist; PFTs: pulmonary function tests; HRCT: high-resolution computed tomography; FeNO: fraction of exhaled nitric oxide; RAST: radioallergosorbent test; CT: computed tomography; ENT: ear, nose, and throat (ie, otolaryngology); HIV: human immunodeficiency virus; echo: echocardiogram; PASP: pulmonary artery systolic pressure; PH: pulmonary hypertension; CPAP: continuous positive airway pressure; QTc: corrected QT interval; IBS: irritable bowel syndrome; IBD: inflammatory bowel disease.

* The Epworth sleepiness scale and STOP-Bang questionnaire are scores to assess for likelihood of sleep-disordered breathing

¶ Initiating treatment with roflumilast 250 mcg once daily for four weeks and then increasing to 500 mcg once daily may reduce the rate of treatment discontinuation due to gastrointestinal side effects. However, 250 mcg once daily is not a therapeutic dose and should not be used long-term.

Δ Chronic bronchitis is defined by productive cough for more than three months in the past two consecutive years.

◊ Dosing of dupilumab is typically a 600 mg loading dose subcutaneously once, followed by 300 mg every other week. Patients should be monitored for injection site reactions. Although symptomatic hypereosinophilia is rare, patients should be monitored for these symptoms (rash, fevers, arthralgias) with a white blood cell (WBC) differential if symptoms warrant. Cost, needle phobia, and logistical difficulties may limit use of dupilumab. Patients who do not benefit after 6 to 12 months should not continue dupilumab therapy.