Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
24 October 2007

SHORTNESS OF BREATH – 3:  TREATMENTS FOR

 CHRONIC OBSTRUCTIVE LUNG DISEASE (COPD)

            Chronic obstructive lung disease results from blocking the airway passages to the air sacs in the lung.  It is in the billions of tiny air sacs that exchange of carbon dioxide and oxygen occurs.  But for this exchange to occur, the air has to get there first.  Worse than a busy airport, the air “has to get in and get out quickly”.  Disease processes that prevent this are really only three in number.  First, the muscles in the tubes that carry air down to the air sacs can contract too tightly as in asthma.  Secondly, secretions and mucous in the lungs can become excessive and thick and block the air passages.  And third, the walls of the air passages can become inflamed from infection or allergens or inflammatory processes.  There are treatments directed to all of these available.

            The backbone of treatment for chronic obstructive lung disease is directed at relaxing the muscles in the walls of the air passages.  This is the most quickly reversible disease process.  There are medications that can relax these muscles within minutes, as in the treatment of asthma.  The most widely used of this type of product is called albuterol.  It comes as a generic “medi-haler”.  This is a small canister held in the palm of the hand that is sprayed into the mouth as a person takes a deep breath.  The deep breath sucks the medication down into the lung passages and allows those muscles to relax.  Used 4 times a day, this costs about $20-30.00 per month.  There is an alternative medication called levalbuterol (Xopenex).  It lasts somewhat longer and can be used 3 times a day.  It has the advantage of causing a less rapid heartbeat and jittery feelings.  However, the cost is around $60.00 per month. 

            For patients with longstanding disease, the use of a “nebulizer” is sometimes helpful.  It is not as mobile as the handy little medi-haler that can be slipped in a person’s pocket.   It is a more effective delivery system involving a watery fog carrying the medicine down into the lungs.  The treatment takes somewhat longer than the quick use of the hand held inhaler.  Depending upon the insurance system, the albuterol for a nebulizer may be $10-$15.00 per month or the Xopenex can be as much as $40.00 per month.  There is a new very long acting medication being touted as a twice a day nebulized medication.  This is called arformoterol (Brovana).  As all new patent protected medications, this is very expensive at $280.00 a month.  It is very new and experience is still being developed.  There are additional products that provide 12-hour relaxation of the muscles in the airways.  These are called salmeterol (Serevent) and formoterol (Foradil).  These are dry powders that are inhaled through a dispensing device that can be carried in the pocket or purse.  These are somewhat more expensive ranging from $100-$120.00 per month.

            The second thrust of treatment for COPD is medication that decreases the secretions in the airway passages.  The first of these was called ipratropium (Atrovent).  It is also available as a handheld inhaler or as a medication one can put into a nebulizer.  There are arguments today as to whether or not this medication was really helpful.  Its cost is around $75.00 a month.  A better product that has evidence-based data showing a superior effect is tiotropium (Spiriva).  This is also provided as a dry powder hand-held inhaler.  Unfortunately, it is very expensive at about $130.00 per month. 

            As a general rule in medical practice, small amounts of 2 or 3 medications always work better than a lot of one and thus there are several combination products on the market.  One of these is called a Combivent inhaler.  It combines albuterol and ipratropium at the same time in a handheld inhaler.  This costs about $85.00 a month.  If one uses the combination product for a nebulizer, the product is called Duoneb and costs about $130.00 a month for the combination product.  Purchased separately the albuterol and ipratropium cost only $60.00.

            The third thrust of treatment is the anti-inflammatory products.  These are all cortisone based but with the special property of not being absorbed into the systemic circulation of the body.  Instead they are limited to the lung surfaces where they act to decrease inflammation.  These products are Pulmicort, Azmacort, or Flovent among several.  Most are used twice a day and cost  $90.00-$180.00 a month. 

            Of course, pharmaceutical companies recognize the value of combination products.  There is a product called Advair which is a mixture of a cortisone product and a bronchodilator.  This costs about $180.00 a month.  This one is a powder inhalant.  Some individuals find the powders difficult and irritating to use and prefer the new product called Symbicort which is a handheld inhaler.  This costs $160.00-$220.00 a month. 

              As can be seen above, COPD is an incredibly expensive disease and while I have been chastised for harping on the problem too much and too long, stopping cigarettes is a lot cheaper.

            Often times, individuals with chronic obstructive lung disease develop infections in the bronchial tubes.  This will require an antibiotic, sometimes hospitalization and usually leaves some residual damage after the infection is treated.  Many of the patients that I care for with COPD are prescribed antibiotics for the first ten days of each month from September until May.  A different antibiotic is used on each occasion cycling 3-5 different products depending upon the person’s allergies.  This has evidence-based medicine from the distance past showing clearly that it prevents hospitalizations and infections during the troublesome winter months.

            Lastly, the late stages of COPD usually require oxygen supplementation.  The oxygen clearly works better if used continuously as opposed to “intermittently as needed”.

            For patients in whom COPD is secondary to chronic asthma, any or all of the asthma medications can be some additional help to the products mentioned above.  Each patient is an individual and whether one uses a metered dose inhaler or a nebulizer or a dry powdered inhaler depends upon the individual person.  Unfortunately, in today’s managed care environment, some products are covered for one person and different ones for another person complicating the problem.  The healthcare providers at your local clinics struggle with the managed care and the preauthorization problems but can be a very special help in alleviating the symptoms of people with COPD.

This and other columns available at www.macpierre.com.