Chronic obstructive pulmonary disease (COPD) is a respiratory disease that causes airflow obstruction in the lungs.

COPD is the third-leading cause of death in the United States, and about 15.7 million Americans have been diagnosed with the disease. Tobacco smoke is a major factor in the development and progression of COPD. Other causes include exposure to air pollutants at home or in the workplace, genetic factors, and respiratory infections. Long-term exposure to cigars, gases from fires, marijuana, and pipes can lead to bronchitis or emphysema. Bronchitis is the narrowing of the bronchial tubes, resulting in mucus production, and emphysema is the destruction of small passages within the lungs called alveoli.1 Individuals with alpha-1 antitrypsin (AAT) deficiency are at a higher risk of developing COPD, because AAT helps protect the lungs from damage resulting from inflammation.2

Spirometry is required to assess the lung function and to make a COPD diagnosis. Spirometry measures the total amount of air an individual can breathe out, also called force vital capacity (FVC). It measures force expiratory volume (FEV1), which is the amount of air exhaled in 1 second. The post-bronchodilator FEV1 is assessed using spirometry, which helps determine the severity of the disease.

Symptoms of COPD include and excess phlegm, mucus, or sputum production; frequent coughing or wheezing; and shortness of breath. Treatment helps decrease the symptoms and prevents further complications, such as exacerbation and hospitalization.1

Patients’ airflow limitation with a post-bronchodilator forced expiratory volume/forced vital capacity (FEV1/FVC) <0.7, is classified based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines as either GOLD 1 (mild), GOLD 2 (moderate), GOLD 3 (severe), or GOLD 4 (very severe).1 Patients’ symptoms burden and risk of exacerbation are classified into GOLD groups A through D, and this is used to guide patients therapy. Classification of airflow limitation (grades 1 through 4) and symptom burden with exacerbation risk (groups A through D) is patient-specific and can occur in a variety of combinations.3
           
Bronchodilators are the first-line therapy for all patients. With COPD disease progression, combination therapy is often required to control the symptoms, which include 2 bronchodilators, such as a long-acting beta-2 agonist (LABA), plus a long-acting muscarinic antagonist (LAMA). This therapy can be combined with an inhaled corticosteroid (ICS), as well, depending on the severity of the disease.1 Inhaled corticosteroids inhibit the inflammatory response. Long-acting beta-2 agonists bind to beta-2 receptors, causing relaxation of bronchial smooth muscles, which leads to bronchodilation. Long-acting muscarinic antagonists cause bronchodilation by blocking the constricting action of acetylcholine at M3 muscarinic receptors in the bronchial smooth muscle. Trelegy Ellipta (fluticasone furoate, umeclidinium, and vilanterol inhalation powder) and Breztri Aerosphere (budesonide, glycopyrrolate, and formoterol fumarate) inhalation aerosol, are the new triple combination therapy options that are FDA-approved for patients with COPD.4

Trelegy Ellipta is a combination of 3 active ingredients. They are fluticasone furoate, an inhaled corticosteroid; umeclidinium, an anticholinergic; and vilanterol, a long-acting beta-2-adrenergic agonist (LABA). The FDA approved Trelegy in September 2017, and it is manufactured by GlaxoSmithKline pharmaceutical. Trelegy is indicated for the long-term, once-daily, maintenance treatment of airflow obstruction in patients with COPD. It is also indicated to reduce exacerbations of patients with COPD who have a history of exacerbations. The most common adverse reactions are back pain, bronchitis, headache, oral candidiasis, pneumonia, and upper-respiratory-tract infection.5

Breztri Aerosphere is a combination of budesonide, an inhaled corticosteroid; formoterol fumarate, a LABA; and glycopyrrolate, an anticholinergic agent. The FDA approved Breztri in July 2020, and it is manufactured by AstraZeneca. Breztri is indicated for the maintenance treatment of patients with COPD. The most common adverse reactions are back pain, oral candidiasis, pneumonia, and upper-respiratory-tract infection.2

Conclusion
With COPD, the limitation of airflow is not fully reversible, which leads to a gradual loss of lung function. Early detection may change the course and progression of the disease. There are variety of inhalers in the market for the treatment of COPD. First-line therapies are dependent upon a patient’s GOLD classification, as well as other factors, such as cost and type of inhaler.1 The hope is for the patients who receive a COPD diagnosis to be treated with the correct inhalation regimens, then with combination therapies, such as those mentioned above, decreasing the frequency of emergency department visits and have hospitalizations.
 

Saro Arakelians, PharmD, is vice president of pharmacy operations at Mini Pharmacy in Los Angeles, California.

Sagar Shah is a PharmD candidate at West Coast University's School of Pharmacy in Los Angeles.


REFERENCES
  1. CDC. Basics about COPD. Updated July 19, 2019. Accessed July 27, 2020. https://www.cdc.gov/copd/basics-about.html
  2. GOLD. Global Initiative for Chronic Obstructive Lung Disease. Accessed July 27, 2020. https://goldcopd.org/
  3. Roth OZ, Crocetta NP, Ostroff ML. A review of the 2019 GOLD guidelines for COPD. U.S. Pharmacist. July 17, 2019. Accessed July 29, 2020. https://www.uspharmacist.com/article/a-review-of-the-2019-gold-guidelines-for-copd
  4. Breztri Aerosphere [prescribing information). Wilmington, DE: AstraZeneca; 2020. Accessed November 10, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/212122s000lbl.pdf
  5. Trelegy Ellipta [prescribing information]. Research Triangle Park, NC: GlaxoSmithKline; 2017. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/209482s000lbl.pdf