Treatment of patients with frequent COPD exacerbations despite inhaled therapies

COPD: chronic obstructive pulmonary disease; CPAP: continuous positive airway pressure; CT: computed tomography; echo: echocardiogram; ENT: ear, nose, and throat (ie, otolaryngology); FeNO: fraction of exhaled nitric oxide; FEV₁: forced expiratory volume in one second; HIV: human immunodeficiency virus; HRCT: high-resolution computed tomography; IBD: inflammatory bowel disease; IBS: irritable bowel syndrome; ICS: inhaled glucocorticoid (aka inhaled corticosteroid); LABA: long-acting beta-agonist; LAMA: long-acting muscarinic antagonist; PASP: pulmonary artery systolic pressure; PFTs: pulmonary function tests; PH: pulmonary hypertension; QTc: corrected QT interval; RAST: radioallergosorbent test.

* Dosing of dupilumab is typically 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 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.

¶ Initiating treatment with roflumilast 250 mcg once daily for 4 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 The Epworth sleepiness scale and STOP-Bang questionnaire are scores to assess for likelihood of sleep-disordered breathing.

◊ Chronic bronchitis is defined by productive cough for more than 3 months in the past 2 consecutive years.