Inhaled short-acting bronchodilators
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IN CHRONIC obstructive pulmonary disease (COPD), airways in the lung are partially obstructed. It's often a mixture of two
diseases, chronic bronchitis and emphysema. The condition is marked by a progressive decline in lung function.
Cigarette smoking is the cause of 85% of COPD cases, so the primary strategy for preventing COPD is to help patients stop
smoking. Breathing in other lung irritants, such as pollution, dust or chemicals, also may cause or contribute to COPD. This
condition develops slowly and is generally diagnosed in middle-aged or older people. It is the fourth-leading cause of death
in the United States.
Inhaled long-acting broncholdilators
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Various medications are used to reduce shortness of breath, improve quality of life, and minimize complications. Patients
with intermittent symptoms benefit from an inhaled short-acting bronchodilator. These patients often have symptoms associated
with exertion, and short-acting medications increase their ability to exercise.
Patients with chronic symptoms and significant airflow obstruction need regular treatment with a long-acting bronchodilator,
either an inhaled long-acting beta2-agonist or an anticholinergic. These agents relieve symptoms, increase exercise tolerance, improve lung function, and reduce
the frequency of exacerbations. Currently three long-acting beta2-agonists are available: Serevent (salmeterol xinafoate), Foradil (formoterol fumarate), and Brovana (arformoterol tartrate).
"Regular use of long-acting bronchodilators can decrease the number of acute exacerbations," says Mark Abramowicz, MD, editor
of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs. "Tolerance to adverse effects, as well as to some of the therapeutic
effects, does occur with regular use." The only long-acting anticholinergic agent available in the United States is Spiriva (tiotropium). "When patients are not
adequately controlled with a single long-acting bronchodilator, combining tiotropium with a long-acting beta2-agonist may be helpful," Dr. Abramowicz says. A study is underway to determine whether tiotropium decreases the progressive
decline of lung function seen in COPD; results are expected sometime this year.
A major focus of COPD treatment is to reduce the frequency and severity of exacerbations. "Treatment includes intensification
of short-acting bronchodilators, short-term therapy with systemic corticosteroids, and usually a course of antimicrobial therapy."
says Dr. Abramowicz. "Short-acting beta2-agonist are generally used first and have been shown to be safe in this use. For patients with severe COPD who experience
frequent exacerbations, a trial of added inhaled corticosteroids is recommended."
COPD DISEASE MANAGEMENT
BlueChoice HealthPlan of South Carolina, a 214,000-member subsidiary of BlueCross BlueShield of South Carolina, set up its
COPD disease management program nine years ago. The plan uses claims, lab, and pharmacy data to identify members with COPD.
All members with COPD receive educational information about the condition. Those at medium risk receive phone call interventions
throughout the year, plus an opportunity for a home-based respiratory care therapist to visit. High-risk members receive more
frequent calls, and may participate in case management if their condition warrants it.
"We also communicate with physicians when we enroll their patients into our program," says Linda Long, MD, MPH, the plan's
chief medical officer and vice president of health services. "We provide copies of evidence-based guidelines on COPD, and
a handbook encouraging physicians to perform spirometry."
