The PRAXIS Nexus The PRAXIS Nexus

A Tale of Too Many Options

Posted on April 08, 2024   |   

This post was written by: Michael W. Hess, MPH, RRT, RPFT.

In many ways, the current pharmacological landscape represents a Dickensian combination of the best of times and worst of times. We have never had as many options for inhaled medications to help manage COPD symptoms as we do now. We have more on the horizon, along with other therapeutics that promise to supplement our traditional bronchodilators and anti-inflammatories. Unfortunately, there is a downside to having such a vast array of options. The "paradox of choice" theory suggests that the more choices one has, the more difficult it is the select one with confidence. Couple that with often-confusing (and sometimes conflicting) clinical guidance and an ever-evolving evidence base and it is easy to become overwhelmed.

Fortunately, there are some strategies to guide your clinical decision-making. Keeping your patient's condition, abilities, and goals at the center of the process is essential and will allow you to then tailor a plan to address other concerns.

Where are they on their COPD journey?

According to the latest GOLD recommendations, virtually everyone new to COPD should start with, at minimum, dual bronchodilator therapy. COPD pathophysiology is often a mix of inflammation, mucus hypersecretion, alveolar damage, and bronchial hyperresponsiveness, and the degree to which each contributes to symptom burden can vary widely from person to person. However, the evidence points to the team of long-acting beta-agonist (LABA) and long-acting muscarinic antagonist (LAMA) medications providing some degree of benefit to a significant percentage of the population. That makes them great candidates for initial therapy. Sometimes, they're even available in the same inhaler, making things even easier for a patient getting used to a new medication regimen.

In some cases, it may also be appropriate to bring in an inhaled corticosteroid (ICS), the third common therapeutic class of COPD meds. If your patient can identify two or more symptom flare-ups in the last year, or just one that landed them in the hospital (where many with COPD first get diagnosed), take a look at their latest blood work. Eosinophil counts of over 300 cells/microliter are suggestive of the kind of inflammation that can respond to ICS therapy. There are even a few inhalers that provide this “triple therapy” all in one dose, again making it relatively easy to get started.

Where do they want to go?

As people proceed along their COPD course, patterns or trends often emerge. You may find someone who has an exacerbation at the drop of a hat and is in and out of the emergency room on a regular basis. Conversely, they may never really have a flare-up, but they simply can't seem to get much relief from their dyspnea. You can use these traits to guide potential escalation of therapy. For example, if someone appears to be on the frequent-exacerbation path, you may want to consider adding an ICS if they did not already have one (especially after reviewing their eosinophil count). You may want to add a medication that is not inhaled; roflumilast (a PDE-4 inhibitor) and macrolide antibiotics have evidence to support their use to reduce exacerbation rates. There are also some new meds on the horizon, such as monoclonal antibodies (also called biologics) that can potentially have a dramatic effect on how often someone flares up.

Managing stubborn dyspnea can be a little more complicated. If your patient has been only taking one class of bronchodilators, the first step is usually simply to add the other class. Once you get beyond that, you may want to consider other potential causes of dyspnea, like cardiac issues. You may also want to redouble your non-pharmacological efforts by encouraging exercise (including pulmonary rehabilitation), or revisiting tobacco treatment. Or, it could mean that the medications are appropriate, but the device is a problem for that person.

What else is going on?

Inhaled medications can be extremely effective for breathing disorders, but they are also a lot more complicated than simply taking a pill. Each of the myriad devices on the market has its own steps and techniques to optimize the delivery of its medication. In many cases, people are not trained properly on their device, preventing them from using it correctly. In many others, people may have another health issue that literally prevents them from doing so. It is therefore critical to look at your patient's complete health status in order to prescribe the best combination of drug AND device. Does your patient have coordination or dexterity issues? A metered-dose inhaler, which requires precise coordination between actuation and inhalation to work properly, might not be the best choice. Is their peak inspiratory flow rate compromised? A dry-powder inhaler, which requires a certain amount of “oomph” to disaggregate the powder into an inhalable dry aerosol, may not deliver the medication deep enough into the lungs. Don't forget that patient preference plays a role as well; many people prefer nebulized medications because they feel more confident their medication is being delivered. In addition, be sure to evaluate inhaler competence at least at every visit, as data suggest competence levels can decay in as little as two months.


As Dickens himself might say, these suggestions can help you move from a season of darkness into a season of light in terms of sorting through the therapies and combinations we have to manage COPD. The COPD Foundation has many other resources to help you work with your patients to provide optimal therapy. From our 101 Library, featuring a variety of topics within COPD, to our educational videos covering proper techniques for every type of inhaler and nebulizer on the market today, to our newly-updated Pocket Consultant Guide (PCG) app, which puts the world of COPD at your fingertips, we are here to help!


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