Hronic obstructive pulmonary disease (copd) is a very common condition, which causes shortness



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C

hronic obstructive pulmonary disease (COPD) is a 

very common condition, which causes shortness 

of breath. COPD is an umbrella term for 

conditions including emphysema, chronic bronchitis 

and chronic asthma which is irreversible. The main 

risk factor is smoking or a history of past smoking 

cigarettes. At least one in 10 (10%) adults over the age 

of 40 years have COPD.

Guidelines

Australian guidelines for the management of 

COPD are called the COPD-X Guidelines. The key 

recommendations are summarised in the COPDX Plan: 



 



Case finding and confirm diagnosis 



 



Optimise function 



 



Prevent deterioration 



 



Develop a plan of care 

 



Manage eXacerbations



Research on COPD medications usually measures 

the change in FEV1 (forced expiratory volume in one 

second), as well as patient-related clinical outcomes 

such as: 

 



St George’s Respiratory Questionnaire (SGRQ)



 

Transition Dyspnoea Index (TDI)



The St George’s Respiratory Questionnaire  is a 50-

item questionnaire developed to measure health 

status (quality of life) across symptoms (frequency 

and severity), activity and impacts (psychosocial). TDI 

focal score measures impact of dyspnoea on three 

domains: functional impairment, magnitude of task 

and magnitude of effort.

Treatment 

Current therapies target airflow limitation and 

pulmonary inflammation. The mainstay of treatment 

involves:

 



Inhaled corticosteroids



 

Long-acting beta



2

-agonists (LABAs)

 



Long-acting muscarinic antagonists (LAMAs)



Other treatments include short-acting bronchodilators 

(‘relievers’), oral bronchodilators (theophylline) and 

phosphodiesterase type-4 inhibitors (cilomilast, 

roflumilast).

Short-acting beta

2

-agonists (SABAs) (salbutamol, 



terbutaline) improve lung function and daily 

breathlessness scores. They are usually prescribed 

for use as “rescue” medication, i.e. for relief of 

breathlessness, rather than for regular use.

Short-acting muscarinic antagonists (SAMAs) such as 

ipratropium bromide 



(Atrovent)

 have a longer duration 

of action than short-acting beta

2

-agonists. They 



improve lung function and quality of life. Ipratropium 

bromide has a significantly greater effect on lung 

function compared to beta

2

-agonists alone; in addition 



to improving quality of life and decreasing need for 

oral corticosteroid treatment. However, some studies 

have found that ipratropium bromide is associated 

with an increased risk of adverse cardiovascular 

effects.

Inhaled bronchodilators (LAMAs and LABAs) provide 

symptom relief, improve quality of life and may 

increase exercise capacity. In some patients, a 

response to bronchodilator therapy may require 

treatment for up to two months. 

Inhaled corticosteroids (ICS) should be considered 

in people with moderate to severe COPD and 

frequent exacerbations. ICS include fluticasone, 

beclomethasone, budesonide and ciclesonide. They 

all may increase the risk of local oropharyngeal 

adverse effects and pneumonia; although risk of 

any pneumonia event has been found to be higher 

with fluticasone than budesonide. Long term use of 

systemic corticosteroids (prednisone, prednisolone) is 

not recommended.



LAMAs

Tiotropium improves quality of life, increases the 

number of patients with a clinically significant 

improvement, and reduces the number of patients 

with a clinically significant deterioration in quality of 

life. The newer LAMAs (umeclidinium, aclidinium and 

glycopyrronium) have been shown to be non-inferior 

to tiotropium, that is, they are just as effective as 

tiotropium.

LAMA/LABAs

January 2016



LAMAs include:

 



Tiotropium 

(Spiriva Handihaler 

and 


Respimat)

 



Umeclidinium 

(Incruse Ellipta)

 



Aclidinium 

(Bretaris Genuair)

 



Glycopyrronium

 (Seebri Breezhaler)

Aclidinium is administered as one inhalation twice 

daily. Twice daily dosing improves early-morning 

symptoms (early morning cough, wheeze, shortness 

of breath, phlegm) and night-time symptoms 

(reduced frequency of breathlessness, cough, sputum 

production, wheezing).

Other LAMAs are administered once daily. There is no 

rationale to combine different LAMAs, either alone or 

in combination with LABAs.



LABAs

Long-acting beta

2

-agonists cause prolonged 



bronchodilatation and can be administered once 

(indacaterol, Olodaterol, vilanterol) or twice daily 

(salmeterol, eformoterol). LABAs used for at least four 

weeks produce statistically significant benefits in lung 

function, quality of life, use of ‘reliever’ short-acting 

bronchodilators and acute exacerbations. LABAs do 

not significantly reduce mortality or serious adverse 

events.


LABAs include:

 



Salmeterol 

(Serevent Inhaler 

and


 Accuhaler)

 



Indacaterol 

(Onbrez Breezhaler)

 



Eformoterol 

(Oxis Turbuhaler)

 



Olodaterol 

(Striverdi Respimat)

 



Vilanterol 

Vilanterol is currently only available in combination 

products with a LAMA umeclidinium 

(Anoro Ellipta) 

and 


ICS fluticasone furoate 

(Breo Ellipta)

.

Combination therapy

When residents are not adequately controlled with a 

single long-acting bronchodilator, combining a LAMA 

and LABA may be beneficial. 

A 2012 Cochrane systematic review of five studies 

found that the combination of tiotropium and a long-

acting beta

2

-agonist provided small improvements 



in health-related quality of life and bronchodilation, 

compared to tiotropium alone. A recent systematic 

review of currently available randomised trials 

of LAMA/LABA combinations for stable COPD 

demonstrated that LAMA/LABA combinations yield a 

greater improvement in trough FEV1, and SGRQ and 

TDI scores than monotherapies.  The review concluded 

that combination therapy is the most effective strategy 

in improving lung function, quality of life, symptom 

scores and moderate-to-severe exacerbation rates. 

Safety outcomes and severe exacerbations are similar 

with combination therapy when compared with 

monotherapies.

Current COPD treatment guidelines recommend 

a combination of a LAMA/LABA as an option for 

patients with significant symptoms and a low risk of 

exacerbations, patients with few symptoms and a 

high risk of exacerbations, and patients with many 

symptoms and high risk of exacerbations.

From 1 December 2015, four LAMA/LABA fixed-dose 

combination bronchodilators are PBS listed for adults 

with COPD:

 



Eformoterol /aclidinium



 (Brimica Genuair)

 



Indacaterol/glycopyrronium 

(Ultibro    

 

 Breezhaler)

 



Olodaterol/tiotropium 

(Spiolto Respimat)

 



Vilanterol/umeclidium 

(Anoro Ellipta)

Eformoterol /aclidinium



 (Brimica Genuair)

 must 


be administered twice daily; whereas the other 

combination products are once daily. Olodaterol/

tiotropium

 (Spiolto Respimat)

 requires two inhalations 

once daily. The Respimat device should be loaded and 

primed by the dispensing pharmacist. Indacaterol/

glycopyrronium 

(Ultibro Breezhaler)

 consists of 

a capsule containing dry powder inhaled via a 

Breezhaler once daily at same time each day, which 

may require sufficient dexterity to load the capsule in 

the device. Genuair and Ellipta devices are likely to be 

easiest to use in older people with limited dexterity as 

they are pre-loaded with the active ingredient.  



Device technique

It is critical that the inhaler device is used correctly 

during every administration. Metered dose inhalers or 

puffers should always be used with a spacer in older 

people.

 

A fixed-dose combination inhaler may be more 



convenient for residents rather than separate single-

drug inhalers. Evidence suggests the drugs within each 

class of LAMAs and LABAs are broadly similar, so the 

choice of treatment may be tailored to ease of use of 

the different devices. 

References

Cochrane Database Syst Rev 2012;4:CD008989

Thorax 2016;71:15-25.

COPD-X Guidelines – Version 2.43 (September 2015)

LAMA/LABAs

© Manrex Pty Ltd (ABN 63 074 388 088) t/as Webstercare - 2015 Webstercare and The W Device are Registered Trade Marks of Manrex Pty Ltd t/as Webstercare.



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