Patient education: Medicines for chronic obstructive pulmonary disease (COPD) (The Basics)

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What do chronic obstructive pulmonary disease medicines do? — If you have chronic obstructive pulmonary disease (also called 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

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 (from other people's smoking).

Which medicines might I need? — There are several different medicines available to treat COPD. Most people use inhalers that help open up their 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. The doses and choices of medicines you need might change if your symptoms change over time.

The list below gives basic information on COPD inhalers and other medicines, and the table lists the names of common COPD medicines (table 1). Your doctor, nurse, or pharmacist will explain how to use your inhalers.

Inhaler medicines to treat COPD

Bronchodilator inhalers – Bronchodilator inhalers 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.

Bronchodilator inhalers 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 – Short-acting beta agonists, or "SABAs," 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 – Ipratropium is a short-acting muscarinic antagonist, or "SAMA." 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 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 – Long-acting beta agonists, or "LABAs," 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. This medicine 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 – Long-acting muscarinic antagonists, or "LAMAs," are also called "long-acting anticholinergics." They include tiotropium (brand name: Spiriva), glycopyrrolate (glycopyrronium) (brand name: Seebri Neohaler), 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. These are listed in the table (table 1).

●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 your 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 need to rinse your mouth out and gargle with water afterwards. These are not the same as the steroids some athletes take illegally.

How do I use the different kinds of COPD inhalers? — Medicines for COPD come in different kinds of inhalers, and each kind has its own directions.

For example, you need to prepare metered dose inhalers (also called "MDIs" or "HFA inhalers") before using them for the first time, or if you haven't used them in more than a week or 2. This is called "priming" the inhaler. You get them ready by shaking them 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 metered dose inhalers comes out in a "puff."

On the other hand, 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 that 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 when you breathe in (inhale) from the device. You might not feel or taste it, even when using the inhaler correctly.

The soft mist (Respimat) inhaler does not need to be shaken before use, but you do need to insert the canister into the holder and follow a couple of steps to get it ready for use (table 2). You will need to prime the inhaler before using it the first time or if you haven't used it in more than 3 days. Unlike other inhalers, the medicine comes out in a mist.

Your doctor, nurse, or pharmacist can explain how to use the inhaler you are prescribed. Most patients find it easy to use an inhaler once someone shows them how.

More information about how to use each type of inhaler can be found in the tables:

●Metered dose inhalers (table 3)

●Dry power inhalers (table 4)

●Soft mist inhalers (table 2)

What if I have a COPD flare? — A COPD flare is when symptoms suddenly get worse. Doctors sometimes call flares "exacerbations." If you have a flare, you might need some 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:

●Short-acting beta agonists (SABAs) and short-acting muscarinic antagonists (SAMAs) – You might need to take extra puffs from the SABA or SAMA inhaler. Or you might take these medicines from a nebulizer.

●Steroids that come in pills – Most likely, you will 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 that come in an "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 in the hospital.

●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 need an IV antibiotic.

How can I prevent flares of my COPD? — If you have COPD, you need a flu shot every fall and the pneumonia vaccine at least once. You should also get vaccinated against COVID-19. This is because infections like the flu, pneumonia, and COVID-19 can be very hard on your lungs. It is important to try to prevent them.

People who have more than 2 COPD flares a year might need a medicine to help prevent them. These include:

●Azithromycin – This is an antibiotic pill that is taken at a low dose. It can help prevent flares in some people, but is not used in everyone with COPD. That's because azithromycin can cause other problems.

●Roflumilast – This medicine comes in a pill you take by mouth. It can help reduce flares in some people with chronic bronchitis and severe COPD.

It is a good idea to keep a list of all the medicines you take and bring it with you every time you visit a doctor or nurse. You can find an example of this kind of list at the following website: www.fda.gov/drugs/resources-you-drugs/my-medicine-record

For more detailed information about your medicines, ask your doctor or nurse for information from Lexicomp available through 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.