Chronic obstructive pulmonary disease (COPD) is the fourth-leading cause of death in the world, and it is predicted to be the third by 2020.1 This preventable and treatable disease is characterized by airflow blockage and breathing-related issues.

Sixteen million individuals in the United States have diagnosed COPD, and there are millions more who do not know they have it.2,3 Smoking is the top cause of COPD, and it is responsible for about 80% of COPD-related deaths.3 Even though there is no cure, there are pharmacological therapies that can reduce symptoms.

Because the incidence of COPD has increased, the National Action Plan (NAP) was created to help manage the disease. This comprehensive plan has 5 goals (figure).3

PREVENTION AND MAINTENANCE THERAPY CONSIDERATIONS
It is important to increase awareness about COPD, and pharmacists, along with other health care professionals, can play an important role through an interdisciplinary approach. Media campaigns, smoke-free policies, and smoking-cessation programs, and tobacco price increases are crucial parts of patient education.1 Smoking cessation is extremely important, and pharmacists can educate patients about nicotine replacement treatment options1 and incorporate the 5-step process of Ask, Advise, Assess, Assist, Arrange, which is separate from the 5 NAP goals, to assist patients who are willing to quit.The effectiveness and safety of e-cigarettes for smoking cessation is uncertain. E-cigarettes can contain nicotine, along with other harmful substances, and defective batteries have caused explosions, resulting in serious injuries.4 Individualizing treatment options is important based on cost and lifestyle.

Vaccinations are crucial for patients with COPD. Getting an annual influenza vaccine reduces death and serious illness. Also, evidence shows that the 23-valent pneumococcal polysaccharide vaccine reduces the incidence of community-acquired pneumonia in patients with COPD who are younger than 65 and have a forced expiratory volume less than 40% predicted and in individuals with comorbidities. The 13-valent conjugated pneumococcal vaccine is effective in reducing bacteria and serious invasive pneumococcal disease in adults 65 and older.

Bronchodilator medications are used regularly to prevent or reduce COPD symptoms. The beta2-agonists consist of short-acting beta agonists (SABAs) and long-acting beta agonists (LABAs). SABAs should not be used on aregular basis,1 because their effects usually wear off within 4 to 6 hours. Indacaterol (Arcapta Neohaler) is a once-a-day LABA that improves breathlessness, exacerbation rate, and health status, and patients may experience a cough after inhalation.1 Other adverse effects (AEs) of beta2-agonists may include hypokalemia, tachycardia, and tremor.

Anticholinergic drugs can be long acting (tiotropium, revefenacin) or short acting (ipratropium, oxitropium). The most common AE is usually mouth dryness. Revefenacin (Yupelri) is a new long-acting anticholinergic medication approved November 8, 2018.5 The recommended dose is one 175-mcg vial administered once a day by nebulizer. The most common AEs are cough, nasopharyngitis, upper respiratory tract infection, headache, and back pain.Patients should avoid taking other anticholinergic drugs in combination with revefenacin. Additionally, avoid coadministration of revefenacin with OATP1B1 and OATP1B3 inhibitors (eg, rifampicin, cyclosporine). Methylxanthines include theophylline, and there is mixed evidence regarding their benefit on exacerbation rates; toxicity is dose-related.5

Inhaled corticosteroids are more effective when used in combination with a LABA than as monotherapy.1 Oral glucocorticoids can treat acute exacerbations in the hospital setting. However, these medications should be avoided in daily COPD management because they lack benefit for long-term use and have been shown to cause AEs, including steroid myopathy, which can lead to muscle weakness and respiratory failure. Evidence suggests that pulmonary rehabilitation programs can improve dyspnea, exercise tolerance, and health. Long-term use of oxygen therapy greater than 15 hours per day can increase survival in patients with hypoxemia or low-blood oxygen levels.1

The first generic of fluticasone propionate and salmeterol (Advair Diskus) was approved January 30, 2019.6 Pharmacists can also play an important role in counseling patients on appropriate inhaler use, which depends on the type. Adherence and compliance should be addressed when patients are picking up their medications from the pharmacy. Ensure that patients using inhalers that have been on the market for years do the following: form a seal around the mouthpiece with the lips, hold their breath long enough after inhaling a dose (10 seconds); and exhale completely before each dose.7 Newer inhalers have a variety of features, including a dose counter and longer spray duration at a lower speed.
 
Jennifer Gershman, PharmD, CPh, is a drug information pharmacist and Pharmacy Times®contributor who resides in South Florida.

REFERENCES
  1. Global Initiative for Chronic Obstructive Lung Disease Pocket Guide to COPD Diagnosis, Management, and Prevention: A Guide for Health Care Professionals, 2019 Report. Fontana, WI: GOLD; 2019. goldcopd.org/wp-content/uploads/2018/11/ GOLD-2019-POCKET-GUIDE-FINAL_WMS.pdf.
  2. Chronic obstructive pulmonary disease (COPD). CDC website. cdc.gov/copd/index. html. Updated June 5, 2018. Accessed February 15, 2019.
  3. National Institutes of Health. COPD national action plan. National Heart, Lung, and Blood Institute website. www.nhlbi.nih.gov/health-topics/education-and-awareness/ COPD-national-action-plan. Accessed February 16, 2019.
  4. Gershman J. E-cigarette injuries on the rise. Pharmacy Times®. October 10, 2016. pharmacytimes.com/contributor/jennifer-gershman-pharmd-cph/2016/10/e-cigarette- injuries-on-the-rise. Accessed February 16, 2019.
  5. Yupelri [prescribing information]. Morgantown, WV; Mylan Specialty, LP; 2018. www.accessdata.fda.gov/drugsatfda_docs/label/2018/210598s000lbl.pdf. Accessed February 17, 2019.
  6. FDA approves first generic Advair Diskus [news release]. Silver Spring, MD: FDA; January 30, 2019. www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ ucm630151.htm. Accessed February 17, 2019.
  7. Institute for Safe Medication Practices. Breathing easier: safe use of inhaled med- icines. ISMP website. ConsumerMedSafety.org website. consumermedsafety.org/ medication-safety-articles/item/805-breathing-easier-safe-use-of-inhaled-medicines. Published June 3, 2016. Accessed February 17, 2019.