Conventional COPD Treatments

Allopathic Medicine

Before we look at the conventional treatments for COPD we need an understanding of allopathic medicine so we understand why these treatments focus on the symptoms or “effects” of the disease and not the “cause.”

The doctors providing most of the treatments for COPD are MD’s or “allopathic” medical doctors.

According to Merriam Webster, the medical definition of ALLOPATHY is:
1. a system of medical practice that aims to combat disease by use of remedies (as drugs or surgery) producing effects different from or incompatible with those produced by the disease being treated. 2. a system of medical practice making use of all measures that have proved of value in treatment of disease.

Compare this with Homeopathy, which Merriam Webster defines as “a system of medical practice that treats a disease especially by the administration of minute doses of a remedy that would in healthy persons produce symptoms similar to those of the disease.”

Conventional COPD treatments generally use a multipronged approach including bronchodilators which come in 2 forms, beta2 agonists and anticholinergics.

Bronchodilators

Bronchodilators work by dilating airways which decreases airflow resistance. For this reason they are generally the primary medication prescribed for COPD patients. While these drugs provide temporary relief from symptoms, they do not decrease mortality or slow the progression of COPD. For this reason, relying on these drugs for COPD treatment alone will result in eventual death. Bronchodilators are provided in an inhaled form using a metered dose inhaler (MDI), dry powder inhaler (DPI), or nebulizer.

2 Types of Bronchodilators: Beta2 Agonists and Anticholinergics Beta2 agonists increase smooth muscle relaxation through a mechanism involving the activation of specific B2-adrenergic receptors that increase intracellular cyclic adenosine monophosphate (cAMP). The side-effects include tachycardia (elevated heart rate) and tremors. Beta2 agonists have also, in rare occasions, caused cardiac arrhythmia.

Anticholinergic medications also called anticholinergic bronchodilators, cause bronchodilation through a process by which they compete with acetylcholine for postganglionic muscarinic receptors which inhibits cholinergically mediated bronchomotor tone. They also block vagally mediated reflex arcs that cause bronchoconstriction. In other words, anticholinergic medications cause bronchodilation and prevent bronchoconstriction. Side-effects include dry mouth, dry eyes, metallic taste, and prostatic symptoms. Clinical benefits of anticholinergic medications and anticholinergic bronchodilators are through a decrease in exercise-induced dynamic hyperinflation.

Researchers in British Columbia found increased hospital stays and emergency room visits with the use of anticholinergic bronchodilators. Other research in British Columbia noted prostate problems associated with the use of these bronchodilators.

Studies have shown that combining both the anticholinergic and the beta2 agonist bronchodilators results in greater bronchodilator response and provides greater relief. Monotherapy with either one, and combination therapy using both, are acceptable options according to the medical industry. Generally speaking, long-acting bronchodilators are more beneficial than short-acting ones.

In a study performed in Ontario, Canada, acute urinary retention (AUR) was significantly more prevalent in users of inhaled anticholinergic meications (IACs) than in those not using these medications.

Inhaled delivery of medications is the preferred method over oral medications which helps minimize adverse effects. With some patients, metered delivery is ineffective so a nebulizer may provide the desired results.

The use of prescribed inhaled long-acting beta-agonist and long-acting anticholinergic drugs for COPD was associated with a 31% increased risk of experiencing a cardiovascular event. This was from a recent nested case-control analysis of a retrospective cohort study.

Both of these types of medications, the beta-agonists and the anticholinergics, showed increased risk of acute coronary syndrome and heart failure but not arrhythmias or stroke. Note here that with both of these types of medications, the risk of adverse events was at its highest in the first 2 to 3 weeks of initiating these treatments.

Results from the SPARK trial in 2013 showed patients with severe COPD who took a fixed-dose combination of a beta2 agonist, indacaterol, and a muscarinic antagonist, glycopyrronium can improve lung functioning and reduce exacerbations as compared with using either glycopyrronium or tiotropium alone. Glycopyrronium and tiotropium are both muscarinic antagonists.

The doctor had prescribed Combivent rescue inhaler. When my mother first got this rescue inhaler she only used it about once a week during an exacerbation so the inhaler would last the full 2 months and then she was allowed another one. After she deteriorated down to End Stage Emphysema under the care of 2 doctors, the frequency of her exacerbations increased considerably and the Combivent would only last a few weeks and sometimes less. I could tell this disease was progressing rapidly!

I wondered why the doctor would not prescribe the Combivent more frequently. I then found out that there was a potential problem with bromide toxicity since the Spiriva, DuoNeb and Combivent all had ipratropium bromide.

Around this same time indacaterol and tiotropium were equally effective at producing improvements in baseline dyspnea (breathlessness) and health status with similar safety profiles. Patients treated with indacaterol had a 29% higher exacerbation rate, but required less frequent use of rescue inhalers than those treated with tiotropium.

Tiotropium did not show a change in the rate of decline of FEV1 or mortality but it did reduce the frequency of exacerbations and hospitalizations.

COPD Medication

Short-acting Beta Agonists – rescue inhalers

Short-acting Anticholinergics� ipratropium and atrovent are prescribed for up to 4 times a day.

Short-acting Combination Inhalers - A combination inhaler that contains albuterol and ipratropium bromide.(Example: Combivent)

Long-acting Beta Agonists - Long-acting beta agonists are recommended if your symptoms are not adequately controlled with other treatments. Examples of long-acting beta agonists include salmeterol, formoterol, and arformoterol, which are taken twice daily, and indacaterol, which is taken once daily.

Long-acting Anticholinergics - tiotropium (Spiriva), which is taken once daily, aclidinium (Tudorza), which is taken twice daily, and umeclidinium (Incruse), which is taken once daily, improve lung function while decreasing shortness of breath and flares of COPD. This type of medication may be recommended if your symptoms are not adequately controlled with other treatments, such as the short-acting bronchodilators.

Long-acting Bronchodiltor Combination Inhalers – use both a long-acting beta agonist and a long-acting anticholinergic medication. Umeclidinium/vilanterol (Anoro) is a dry powder inhaler that is taken once daily, and tiotropium/olodaterol (Stiolto) is a soft mist inhaler that is also taken once daily. This type of dual-bronchodilator therapy helps to improve lung function more than either a long-acting beta agonist or long-acting anticholinergic alone.

Glucocorticoids – also called steroids, although they are not the same anabolic steroids taken by bodybuilders, are a class of medications that have anti-inflammatory properties. Delivery is accomplished via an inhaler, a medication taken orally, or through an injection. These steroids, such as prednisone, are often used for short-term treatment of exacerbations. Prednisone is not used for long-term treatment due to the adverse side-effects associated with this drug. Some of the other inhalers contain steroids such as Advair which contains fluticasone, a steroid. Advair was one of the 8 medications doctors will not take even if they are diagnosed with the disease that warrants their use. You can read about all 8 of these drugs in the May 14, 2008 Edition of Men's Health. If you would like reading the article, click the link below.

8 Drugs Doctors Would Never Take

If your COPD symptoms are not completely controlled with bronchodilators or if you have frequent COPD exacerbations or flares, your doctor may prescribe inhaled glucocorticocoids in combination with your long-acting bronchodilator.

Some of the combinations that exist at the present time are Advair which is fluticasone proprionate/salmeterol and Symbicort which is budesonide/formoterol. These 2 are taken twice daily. Another combination that exists at present that is taken only once daily is called Breo which is fluticasone furoate/vilanterol.

Supplemental Oxygen

Patients with advanced COPD will often have low blood oxygen levels, a condition known as hypoxemia. The patient may not even feel short of breath or have any other definitive COPD symptoms. A simple device called a pulse oximeter can be placed on the finger which measures oxygen levels.

Because of the change in air pressure, some COPD patients experience hypoxemia when flying. In flight supplemental oxygen is available on most commercial airlines.

Supplemental oxygen must never be used while smoking since oxygen is explosive. This seems completely obvious to most of us but apparently to others, it is not so evident.

Supressing your cough with cough syrup or cough drops, even if it becomes bothersome, is not a good idea as it will increase the potential for a lung infection.

Supplemental Therapies for COPD

Quit Smoking: The most important thing you must do first is quit smoking. If you have not done so yet you should explore the various avenues of available help in quitting smoking. Many states will provide free nicotine gum and patches to any resident smoker who asks. Check with the American Lung Association for your state’s contact information.

For me personally, the patches did not work, the gum did not work, I tried aversion therapy which did not work and even hypnosis which also did not work for me. The only thing that worked, and it worked very well, was nicotine inhalers.

These are not the electronic cigarettes which provide nicotine vapor. The nicotine inhalers I used did not produce any smoke or vapor when you used them. They were just very effective. The day I got them in the mail I decided I would wait until I wanted a cigarette and then see how long I could hold off by using the nicotine inhaler. The wildest thing happened! I quit smoking that night! I had no intention of quitting at that time. I was checking how much willpower I would need for success with the nicotine inhalers.

The problem is I think the only way they are available in the United States is with a prescription. I ordered mine through Kiwi Drugs in New Zealand. No prescription needed. It is just nicotine. I saw no reason that I should pay a doctor and a pharmacy when I could buy them direct without a prescription. Ironically, Kiwi Drugs is a drug store however, it is in New Zealand and there is no prescription necessary for nicotine inhalers in New Zealand. Smart!

Pulmonary Rehabilitation – these programs may include a host of activities including education, exercise, breathing techniques and close tracking of your progress. They also provide some helpful interactions between patients that are all going through the same thing. It helps when you see other people who are in your same situation. You don’t feel so lost and alone. These programs have improved patient’s exercise ability, enhanced their quality of life and decreased the frequency of their COPD exacerbations.

Surgery – There are 2 types of surgery used in treating COPD patients that are generally used only when all other treatment modalities have failed and the patient’s symptoms are severe.

Lung Volume Reduction Surgery – lung volume reduction surgery involves removing that portion of the lung that contains air pockets and no properly functioning alveoli. The idea is that by removing those portions of the lung that is not funcitoning properly, it would allow the expansion and proper functioning of the remaining lung.

Results for Lung Volume Reduction Surgery have not always been good. Not all patients undergoing this type of surgery improve and, in fact, sometimes the patient becomes worse after this surgery. They will generally determine if the patient would benefit from this surgery by using an imaging test such as a CT scan.

Lung Transplantation – Lung transplantation is generally considered only in cases of severe COPD when all other possible treatments have failed. At the time of this writing (February 2016), lung transplantation has not significantly prolonged the lives of COPD patients to any noticeable degree.

My Observations With Conventional COPD Treatments

When my mother was first diagnosed with emphysema no symptoms were visible. Less than a year later she was taking multiple conventional treatments which came in the form of inhalers, oral medications and albuterol sulfate for use in the nebulizer.

While the exacerbations (shortness of breath episodes) increased in frequency, it was offset by the temporary masking of symptoms provided by these conventional treatments and medications. Even though these treatments and medications did not produce any permanent improvements, they did provide temporary relief from the debilitating symptoms.

My mother took Mucinex for relief from the excess mucus. I eventually realized that she was not coughing up the mucus. Mucinex was apparently drying up the mucus in her lungs but leaving the residue. Soon after she would have another lung infection which required additional antibiotics. I watched this cycle repeat 3 or 4 times in little more than a year and realized we needed a better solution for the excess mucus problem.

I knew that COPD was essentially a terminal disease even though they had changed the term to “progressive” instead of terminal. I think they thought people would more likely take medications if they had a progressive disease rather than a terminal one.

I realized that the only thing the doctors were prescribing for this terminal disease was medications that would not cure this disease or even stop it from progressing. I realized that if I did not do something in addition to these conventional COPD treatments, my mother would not survive COPD.

The other very troubling thing I noticed was that the prescribed medications stopped working, one at a time, when my mother reached End Stage Emphysema and needed them the most!

The first one that stopped producing the temporary relief of symptoms was the albuterol sulfate. When I contacted the Pulmonary Specialist regarding this problem he changed the prescription from just albuterol sulfate to DuoNeb which was albuterol sulfate along with ipratropium bromide. The DuoNeb worked for a few months longer and then it also stopped producing the temporary relief from symptoms.