In pre-clerkship treatment of diseases like COPD is discussed very generally. LAMA, LABA, and corticosteroids. But how does this translate to clinic practice?
Let’s start with some definitions:
- LAMA or SAMA – long or short acting muscarinic agonist
- LABA or SABA – long or short acting beta agonist
- ICS – inhaled corticosteroids
Treating COPD is a stepwise process. We first start by determining how severe their disease is
- Severity is determined by their FEV1 percentage which is discussed in this article
- Types of inhalation devices is discussed in this article.
MILD COPD = SAMA with or without SABA
If the disease is mild, we start with a SAMA with or without a SABA.
- Some of the common SABAs you will see in practice are ventolin and bricanyl
- A common SAMA you will see in practice is atrovent
The short acting agents are known as rescue puffers because they provide quick symptomatic relief
When the disease is mild you are simply providing symptomatic relief with puffers.
MODERATE or SEVERE COPD = LAMA + SABA prn
If their disease is moderate (or severe) or if symptoms continue to progress or worsen, or if they are having increased number of COPD exacerbations, then we can consider adding some long acting agents as well.
For moderate COPD, we keep the SABA (or SAMA) as prn (as needed), and add a LAMA
- One of the most common LAMAs used is called spiriva
SEVERE to VERY SEVERE COPD = LAMA + LABA + SABA prn, if this fails then move onto LAMA + (ICS+LABA combo) + SABA prn
Let’s say it’s still not controlled even with the long acting agents, then what do you do?
Well we still haven’t tried using LABAs. So if there is still poor symptom control, add a LABA, so now you have LAMA+LABA+SABA prn.
- Common LABAs include oxeze, serevent and onbrez
If the 3 puffers are not doing the trick, it may be time to add some steroids into the mix as well. Usually steroid puffers are not given by themselves (but they can be i.e. pulmicort), but are found in combination with a LABA (henceforth referred to as ICS + LABA).
- Common ICS + LABA combinations include symbicort and advair
So if you have poor symptom control,then treat with a LAMA, ICS+LABA and as always a SABA prn.
High yield points
- Always keep in mind, that a possibility for refractory COPD treatment could be improper inhaler technique!
- As you see above SABA prn is part of every therapy combination; this is because it is the rescue medication for symptomatic management.
- You may consider providing low dose CT screening for patients with an extensive smoking history (although this is controversial!)
- When prescribing ICS combination puffers, remember to tell patients to rinse their mouth afterwards to eliminate excess medication in mouth