Dick D. Briggs

Chronic obstructive pulmonary disease: Epidemiology, pathogenesis, disease course, and prognosis

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and is increasing in incidence. COPD is easily identified in its early stages by spirometry, yet it is still underdiagnosed, largely because this simple test is not being done in patients at risk for the development of COPD. The most important risk factor by far is cigarette smoking-smoking cessation or even a decrease in smoking can substantially reduce the risk for the development and/or rate of progression of COPD. Increased public awareness, early diagnosis and intervention, and secondary prevention by primary care providers may help reverse the trend of escalating prevalence, mortality, and premature morbidity associated with COPD.

Evaluation of withdrawal of maintenance tiotropium in COPD

INTRODUCTION In chronic diseases such as chronic obstructive pulmonary disease (COPD), patients may not perceive all of the benefits of drug therapy until withdrawal. Thus, we evaluated the effect of tiotropium withdrawal on clinical variables. METHODS COPD subjects who participated in two identical 1-year, prospective, double-blind, placebo-controlled studies of tiotropium 18 microg once daily who completed a 3-week visit following discontinuation of therapy were included in this analysis. Outcomes measured included dyspnea (transition dyspnea index [TDI]), Peak Expiratory Flow Rate (PEFR), health status (St Georges Respiratory Questionnaire [SGRQ]), and rescue beta2-agonist use. RESULTS Overall, the tiotropium group exhibited significant improvements in clinical parameters at the end of therapy. Of the entire cohort of 921 patients, 713 patients (77%) completed 3-weeks post-withdrawal evaluation. Patients in the tiotropium group had 1.1 unit worsening in TDI, decreased in PEFR, health status and reduced beta(2)-agonist medication following treatment discontinuation, while the placebo group remained relatively stable. CONCLUSIONS The withdrawal of tiotropium results in worsening of COPD over a three-week interval. There was no evidence of a rebound effect in response to tiotropium withdrawal.

Long-term pharmacologic management of patients with chronic obstructive pulmonary disease

Various pharmacologic agents are available for the long-term maintenance management of chronic obstructive pulmonary disease (COPD). The efficacy of these agents is based on their ability to decrease COPD symptoms, improve pulmonary function and quality of life, and reduce the frequency of acute exacerbations. Bronchodilators form the foundation of COPD therapy. Anticholinergic bronchodilators, such as ipratropium bromide and especially tiotropium, are first-line anticholinergic agents that can be used alone or in combination with long-acting or short-acting beta2-agonists to achieve these primary goals of COPD treatment. Methylxanthines are useful primarily for their nonbronchodilatory (ie, positive) effects on pulmonary arterial pressure, pulmonary vascular resistance, renal blood flow, and glomerular filtration rate. Inhaled corticosteroids are reserved only for the few patients with severe disease who experience symptoms and acute exacerbations despite optimized multiple bronchodilator therapy. This article reviews agents that are currently available and those that are in development for the long-term management of COPD, with special emphasis on the anticholinergic bronchodilators.

Long-term nonpharmacologic management of patients with chronic obstructive pulmonary disease

A comprehensive treatment plan for managing patients with chronic obstructive pulmonary disease (COPD) involves appropriate use of nonpharmacologic as well as pharmacologic interventions. Nonpharmacologic intervention begins with an aggressive effort toward smoking cessation, which has been proven to slow the accelerated rate lung function that characterizes COPD and to decrease all-cause mortality in patients with COPD. Proper nutrition and regular exercise are vital for all patients. Some patients with documented hypoxemia from more severe disease may require long-term oxygen therapy. Pulmonary rehabilitation benefits most patients, and even surgical intervention with lung volume reduction surgery or lung transplantation may help a limited number of patients. This article reviews the nonpharmacologic interventions that may be used in conjunction with maximized pharmacologic therapy in the long-term management of patients with COPD.