Docs debate the best treatment protocols for high-risk COPD patients
Key Takeaways
The care for high-risk COPD can be improved with innovative medications like PDE4 inhibitors, biologics, and GLP-1 receptor agonists, according to the experts.
Non-drug interventions such as pulmonary rehabilitation and lung surgeries become necessary when pharmacotherapy isn’t enough.
Given the complexities of COPD management, including conflicting guidelines and concerns about medication overuse and antibiotic resistance, physicians must continuously refine their treatment strategies based on evolving evidence and individual patient needs.
Managing high-risk COPD patients is one of the most complex challenges in pulmonary care. With limited treatment options, conflicting guidelines, and inadequate palliative care access, physicians are constantly adjusting treatment strategies to improve outcomes.
Board-certified physicians John Lowe, MD; Michael Lahey, MD; and Dr. Alok Mohta, MD, MBBS, spoke with MDLinx to break down current treatment protocols for high-risk COPD patients.
Pharmacological therapies
Inhalational therapy
According to Dr. Lowe, a combination of inhalational long-acting beta-agonists (LABA) and long-acting muscarinic antagonists (LAMA) remains the gold-standard symptomatic treatment of severe COPD. “The strategies currently developed are directed toward improving symptoms and inhibiting disease progression,” he tells MDLinx.
Dr. Lahey notes that triple-inhaler therapy, which includes LAMA, LABA, and inhaled corticosteroids (ICS), has been effective for patients with severe COPD. However, using ICS in combination therapies is contentious among the experts.
While ICS/LABA combinations can reduce exacerbations, the increased risk of pneumonia makes physicians like Dr. Mohta cautious. “We prescribe ICS with a lot of care, particularly because of the elevated pneumonia risk. It’s not for every patient,” Dr. Mohta says.
PDE4 Inhibitors
Dr. Lahey explains the role of phosphodiesterase-4 (PDE4) inhibitors like roflumilast, noting that they help to decrease airway inflammation in patients with serious chronic bronchitis and recurrent acute exacerbations, particularly in treatment-resistant patients.
The 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report describes the role of roflumilast as follows: ”Roflumilast reduces moderate and severe exacerbations treated with systemic corticosteroids in patients with chronic bronchitis, severe to very severe COPD, and a history of exacerbations.”[] Essentially, it improves lung function and benefits those not fully controlled on LABA+ICS.
Biologics
Biologic agents are another area of growing interest.
"Like the treatments applied in asthma, the new group of biologics addressing distinct inflammation processes is now being studied for COPD."
— Michael Lahey, MD
Dr. Lowe shares, “One of the most desired innovations is the use of biologics directed at several inflammatory targets, including IL-5 and IL-4 blockers, which have the potential to prevent exacerbations in patients with high eosinophil counts.”
Recently, dupilumab became the only FDA-approved biologic for poorly controlled COPD. In phase 3 clinical trials, this IL-4/IL-13 inhibitor has shown a significant 34% reduction in exacerbations. The IL-5 inhibitors mepolizumab and benralizumab both demonstrated nearly a 20% reduction in moderate to severe exacerbations.[][]
GLP-1RAs
GLP-1 receptor agonists (GLP-1RAs) can lower the risk of severe exacerbations by 30% in COPD patients with comorbidities like diabetes or obesity.[] "Obesity, diabetes, and heart disease are linked to higher mortality in COPD patients,” Dr. Mohta explains. “More than a third of COPD cases are also obese. GLP-1RAs show promise in reducing mucus secretion, improving lung function, and potentially lowering mortality rates. However, we still need more data to understand their long-term benefits fully."
Related: Can GLP-1s improve COPD symptoms? Experts weigh inShort-term systemic therapy
Short-acting beta-agonists (SABA) and systemic corticosteroids are standard treatments for severe acute COPD exacerbations. According to current GOLD guidelines, systemic corticosteroids reduce treatment failure, prevent relapses, and shorten hospital stays in severe cases.[]
“When a patient comes in with a bad exacerbation, corticosteroids become a necessity to turn things around quickly, but I avoid using them longer than 5 to 7 days due to risk of hyperglycemia and osteoporosis,” says Dr. Mohta.
Another short-term therapy useful in high-risk cases is antibiotics, says Dr. Mohta. However, their use is controversial due to resistance concerns. "Antibiotics can help, especially in infection-prone patients, but the risks must be weighed carefully," he says.
The GOLD 2023 report outlines criteria for antibiotic use in COPD exacerbations to minimize overuse and resistance.[] Antibiotics should be prescribed if patients satisfy any of the following three conditions:
They have all three key symptoms: dyspnea, high sputum volume, and purulent sputum.
They have any two of the above three symptoms, but one of them must be the thicker/discolored sputum.
They need mechanical ventilation, either through a mask or a breathing tube.
Oxygen therapy and non-invasive ventilation
Long-term oxygen therapy (LTOT) is a critical intervention for patients with severe hypoxemia. Studies demonstrate that using oxygen for more than 15 hours daily can improve survival.[] However, as Dr. Mohta cautions, “Not all COPD patients need oxygen, and overuse can do more harm than good. Since LTOT reduces hypoxic respiratory drive, you must monitor patients closely to avoid complications like hypercapnia.”
Non-invasive ventilation (NIV) is another valuable therapy for acute respiratory failure during exacerbations.[] “NIV reduces the need for intubation and hospitalization,” says Dr. Mohta.
It’s important to note that the GOLD report indicates NIV is standard of care for “decreasing morbidity and mortality in patients hospitalized with an exacerbation of COPD and acute respiratory failure.”
Non-pharmacological interventions
"In addition to drugs, elaborate pulmonary rehabilitation is showing itself to be a crucial element in enhancing the quality of life and functional status of COPD patients."
— Michael Lahey, MD
Dr. Lowe says that lung volume reduction surgery is valuable in “carefully selected patients,” noting that when medications alone aren't sufficient, surgery becomes an option for severe emphysema, drastically improving lung function and reducing symptoms. These techniques include removal of damaged tissue and endoscopic reduction with valves to shrink diseased areas. For the most advanced cases, lung transplants may be considered. In less extreme situations, bullectomy can help improve airflow.
What this means for you
We have come a long way in managing COPD, but the disease is still unpredictable and difficult to treat. We need better evidence to guide us, especially in complex and comorbid cases. With limited treatment options, conflicting guidelines, and concerns over the contentious use of inhaled corticosteroids, risks of systemic therapy overuse, and growing issues around antibiotic resistance, physicians must continuously refine their strategies to improve patient outcomes based on clinical experience.