Patient education: Medicines for COPD (The Basics)

Written by the doctors and editors at UpToDate

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What is COPD? —

COPD stands for "chronic obstructive pulmonary disease." It is a lung disease that makes it hard to breathe.

What do COPD medicines do? —

If you have COPD, your doctor can prescribe medicines that will:

●Help you feel better and more able to do everyday activities

●Reduce or prevent COPD symptoms, such as coughing or shortness of breath

●Help reduce the risk of future attacks or flares (also called "exacerbations")

If you smoke, the best thing you can do for your health is to quit smoking. It's also important to stay away from secondhand smoke (other people's smoking).

Which medicines do I need? —

There are several different medicines available to treat COPD. Most people use inhalers. An inhaler delivers medicine directly to the lungs as you breathe in. Some people use a machine called a "nebulizer" to take their inhaled medicines.

Inhaled medicines help open the airways or decrease swelling in the airways. The airways are the branching tubes that carry air inside the lungs (figure 1). Depending on how severe your symptoms are, you might need more than 1 inhaler. You might need to change medicines or doses if your symptoms change over time.

The list below gives basic information on COPD inhalers, medicines given by nebulizer, and other medicines. The table lists the names of common COPD medicines (table 1).

What are the different inhaled medicines for COPD?

●Bronchodilators – These are the main medicines used to treat COPD. They help open the airways. They might also help lower the amount of mucus in the lungs.

Bronchodilators come in different forms. "Short-acting" forms relieve symptoms like shortness of breath quickly. They are usually taken only when you have symptoms. "Long-acting" forms decrease breathing symptoms over time. They are taken every day to help keep symptoms from happening.

Short-acting bronchodilator inhalers include:

•Short-acting beta agonists, or "SABAs" – These include albuterol (salbutamol) and levalbuterol (levosalbutamol). They are called "short-acting" because they work within a few minutes and the effect lasts a short time, about 4 to 6 hours. They relieve shortness of breath quickly by relaxing muscles around the airways. SABAs usually come in a "metered dose" inhaler or a "dry powder" inhaler. They can also be taken by nebulizer, which is a machine that turns the medicine into a fine mist.

•Short-acting muscarinic antagonists, or "SAMAs" – An example is ipratropium. These medicines are also called "anticholinergics." They relax the lung muscle in a different way to open airways and reduce symptoms. This medicine comes in a metered dose inhaler and can also be taken by nebulizer.

•Short-acting combination medicine – A short-acting combination inhaler has 2 medicines in the same inhaler. Taking them together can work better than taking them alone. A combination of a SABA and a SAMA comes in a soft mist inhaler. A SABA and SAMA can also be taken together by nebulizer.

Long-acting bronchodilator inhalers include:

•Long-acting beta agonists, or "LABAs" – These include salmeterol (brand name: Serevent Diskus) and olodaterol (brand name: Striverdi Respimat). These relax the muscles around the airways more slowly than SABAs, but the effects last for 12 to 24 hours. These medicines are often taken as part of a long-acting combination inhaler.

Formoterol is a LABA that starts working quickly, like SABAs, but lasts for 12 hours. It can be used with a nebulizer or mixed with other medicines in combination inhalers. In some countries, but not the US, formoterol is available as a separate inhaler.

•Long-acting muscarinic antagonists, or "LAMAs" – These are also called "long-acting anticholinergics." They include tiotropium (brand name: Spiriva), umeclidinium (brand name: Incruse Ellipta), and aclidinium (brand name: Tudorza Pressair). They help the lungs work better and decrease symptoms over time. They also reduce the risk of COPD attacks, called "flares." A flare is when symptoms suddenly get worse. There are several types of LAMA inhalers, and some are available as a nebulizer. These are listed in the table (table 1).

•Phosphodiesterase inhibitors – Ensifentrine (brand name: Ohtuvayre) is another kind of bronchodilator that works to relax the smooth muscle and reduce swelling in the lungs. It has been found to be effective at reducing COPD attacks or flares. It can only be taken using a nebulizer.

•Long-acting combination medicine – Long-acting combination inhalers come as "dual inhalers" with both a LABA and a LAMA. These are listed in the table (table 1).

●Inhaled steroids – Steroids work by reducing swelling in the airways. If a long-acting bronchodilator inhaler does not control your symptoms, your doctor might prescribe a steroid inhaler, too. Steroids are usually prescribed as a combination inhaler that also contains a LABA. There are also "triple inhalers" with a steroid, LABA, and LAMA. Each time you use an inhaler that contains steroid medicine, you must rinse your mouth out and gargle with water afterward.

How do I use the different kinds of COPD medicines? —

Medicines for COPD come in different kinds of inhalers. Each kind has its own directions. For example:

●If you use a metered dose inhaler ("MDI"), you need to prepare it before using it for the first time, or if you haven't used it in more than a week or 2. This is called "priming" the inhaler. You get it ready by shaking it for 5 seconds, spraying medicine into the air (away from your face), and then repeating these steps 3 times before using the inhaler. The medicine in MDIs comes out in a "puff."

●You do not need to shake or prime most dry powder inhalers (like Diskus, HandiHaler, or Ellipta) before using them.

●Most dry powder inhalers have the medicine in the inhaler device. But the medicine for some dry powder inhalers (called single-dose inhalers, like HandiHaler) comes in a pill you put into the inhaler when it is time to take a dose. The pill does not work if you swallow it. It must be used with the inhaler. The medicine comes out in a fine powder you breathe in from the device. You might not feel or taste it, even when using the inhaler correctly.

●If you use a soft mist (Respimat) inhaler, you need to put in the cartridge to get it ready for use. You also need to prime the inhaler before using it the first time or if you haven't used it in more than 3 days. This involves pressing the button to release a dose. Unlike other inhalers, the medicine comes out in a mist. You do not need to shake the inhaler.

●A nebulizer is a machine that hooks up to a mask or mouthpiece (figure 2). When medicine is added to the nebulizer cup and the machine is turned on, it gets released through the mask or mouthpiece as a fine mist you breathe in. Your nebulizer will come with specific instructions for use.

Your doctor, nurse, or pharmacist can explain how to use your inhaler or nebulizer and how often to use it. Most people find it easy to use an inhaler once someone shows them how.

What if I have a COPD flare? —

A COPD flare, or "exacerbation," is when symptoms suddenly get worse. If you have a flare, you might need new medicines until your symptoms improve. Or you might need to take medicine in a different way than through an inhaler for a while.

Medicines for COPD flares include:

●SABAs and SAMAs – You might need to take extra puffs from the SABA or SAMA inhaler. Or you might take these medicines from a nebulizer.

●Steroids pills – You will likely need to take steroid pills for several days. If you have diabetes, steroid pills can increase your blood sugar. Your doctor can help you manage this.

●Steroids given by "IV" – An IV is a thin tube that goes into a vein. It is usually given in the hospital. A person who has a severe COPD flare might need treatment with IV steroids.

●Antibiotic medicines – You might need to take an antibiotic if you have a lung infection or if your symptoms are more severe. Most often, the antibiotic is given as a pill. If you need to stay in the hospital, you might get an IV antibiotic instead.

How can I prevent COPD flares? —

If you have COPD, it's important to get all the vaccines your doctor recommends. This helps prevent infections that can be hard on your lungs. Most people should get vaccines to protect against the flu, pneumonia, COVID-19, and possibly RSV. Your doctor will tell you exactly which vaccines you need and when to get them.

Some people might need additional medicine to help prevent flares. Your doctor might recommend this if you have 2 or more COPD flares a year, or 1 or more flares a year needing hospital care. Medicines used for this include:

●Azithromycin (brand name: Zithromax) – This is an antibiotic pill taken at a low dose. It can help prevent flares in some people, but is not used in people with certain other medical problems.

●Roflumilast (brand name: Daliresp) – This medicine comes as a pill. It can help reduce flares in some people with chronic bronchitis and severe COPD.

●Dupilumab (brand name: Dupixent) – This medicine is given as a shot under the skin, usually every 2 weeks. It can help prevent flares in people with COPD who have a certain type of allergic inflammation. It is not used in everyone with COPD.

●Ensifentrine (brand name: Ohtuvayre) – This is a newer kind of medicine given by nebulizer. It can reduce flares and might be added to some people's treatment plan.

Keep a list of all your medicines, and bring it with you every time you visit a doctor or nurse. You can find an example at this website: www.fda.gov/media/73856/download.

For more detailed information about your medicines, ask your doctor or nurse for the patient drug information handout from UpToDate. It explains how to use each medicine, describes its possible side effects, and lists other medicines or foods that can affect how it works.

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Patient education: Medicines for COPD (The Basics)