First-Ever Guideline for Preventing Acute COPD Exacerbations

On October 16, 2014, the American College of Chest Physicians announced publication of the first-ever guidelines for prevention of acute exacerbations of chronic obstructive pulmonary disease (COPD).¹ Unlike previous COPD guidelines, this guideline addresses the burden of COPD exacerbations, including the costs and burden of hospitalization, as well as the reductions in quality of life that accompany each exacerbation.¹

According to Canadian Thoracic Society member and Jean Bourbeau, MD, MSc, FRCP(c), who served as the guideline vice chair, “The prevention of acute exacerbations has not been a major focus until recently...These new guidelines fill in the gaps that previously existed for prevention of exacerbations.”¹

The focus on reducing acute exacerbations of COPD may help reduce the enormous costs associated with managing the disease. According to the Centers for Disease Control and Prevention, the cost of COPD management amounted to $49.9 billion in 2010 alone, with approximately half of these costs incurred through the cost of in-hospital exacerbation management.¹

In terms of behavioral change, vaccination, and lifestyle interventions, the guidelines recommend the following²:

· Patients with COPD should receive the 23-valent pneumococcal vaccine, as well as the yearly influenza vaccine.

· For patients who have moderate to severe or very severe COPD and have had an exacerbation in the past 4 weeks, pulmonary rehabilitation may reduce the likelihood of further exacerbations.

· Among patients who continue to smoke, smoking cessation should be pursued aggressively.

o In addition to psychological, behavioral, and physiologic strategies, pharmacologic therapies such as nicotine replacement therapy, antidepressants, and nicotine receptor modifier therapy should be pursued.

In terms of pharmacologic therapy, the guidelines recommend the following²:

· Treatment with a long-acting beta₂ agonist and long-acting antimuscarinic drugs may reduce the risk of experiencing a COPD exacerbation.

· Combination therapy with a short-acting muscarinic antagonist plus a short-acting beta₂ agonist in patients with moderate to severe COPD is recommended over short-acting beta₂ agonist therapy alone. In addition, long-acting beta₂ agonist monotherapy is preferred over short-acting muscarinic antagonist monotherapy.

· Long-acting muscarinic antagonists are preferred over short-acting muscarinic antagonists in patients with moderate to severe COPD.

· Use of systemic corticosteroid therapy is recommended for an initial exacerbation, and may reduce the risk of further exacerbations.

· Use of N-acetylcysteine or oral carbocysteine may reduce the risk of COPD exacerbations. Theophylline should be used with caution due to its narrow therapeutic index.

In a notable departure from previous guidelines, this new guideline recommends use of long-term macrolide antibiotic therapy to reduce the risk of COPD exacerbations in patients with moderate to severe COPD who have had 1 or more exacerbations in the previous year, despite optimal use of a maintenance inhaler.^2-5

The new COPD exacerbation prevention guidelines prioritize use of long- and short-acting antimuscarinic and beta₂ agonist drugs, and provide guidance for use of N-acetylcysteine, carbocysteine, theophylline, oral steroid therapy, and long-term macrolide therapy in patients with COPD. With this new guideline, health care professionals may improve quality of life and reduce hospitalization rates for patients with COPD.

References

1. EuekAlert! First-ever patient care guidelines in prevention of acute exacerbations of COPD. www.eurekalert.org/pub_releases/2014-10/acoc-fpc101614.php. Accessed October 2014.

2. Criner GJ, Bourbeau J, Diekemper RL, et al. Prevention of Acute Exacerbations of Chronic Obstructive Pulmonary Disease: American College of Chest Physicians and Canadian Thoracic Society Guideline [published online October 16, 2014]. Chest.

3. Albert RK, Connett J, Bailey WC, et al. Azithromycin for prevention of exacerbations of COPD. N Engl J Med. 2011;365(8):689-698.

4. Uzun S, Djamin RS, Kluytmans J, et al. Influence of macrolide maintenance therapy and bacterial colonisation on exacerbation frequency and progression of COPD (COLUMBUS): study protocol for a randomised controlled trial. Trials. 2012;13:82.

5. Seemungal TA, Wilkinson TM, Hurst JR, Perera WR, Sapsford RJ, Wedzicha JA. Long-term erythromycin therapy is associated with decreased chronic obstructive pulmonary disease exacerbations. Am J Respir Crit Care Med. 2008;178(11):1139-1147.