Inhaler Therapies to Treat COPD

Drugs Work Differently to Relieve or Prevent Flare-Ups

Woman with short hair using an inhaler
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Inhaler therapies are central to treating people with chronic obstructive pulmonary disease (COPD). Rather than waiting for a pill to deliver medication through the bloodstream, inhalers deliver the drugs to the source of the problem, achieving faster, targeted results.

There are inhalers that contain only one medication (monotherapy) and others that deliver multiple drugs with different mechanisms of actions. The drugs can be broken into three broad categories:

  • Short-acting bronchodilators
  • Long-acting bronchodilators
  • Inhaled steroids

Each works differently in treating or preventing COPD and provides the backbone to which other oral or injectable medications may be added.

Short-Acting Bronchodilators

Some people with COPD will only experience symptoms (shortness of breath, wheezing) when exerting themselves. For these individuals, doctors will typically prescribe a short-acting bronchodilator, also known as a rescue inhaler.

Bronchodilators work by opening (dilating) the air sacs (bronchioles) that become constricted during a COPD flare-up. Short-acting bronchodilators are "fast on and fast off," meaning that they work quickly and provide relief for around four to six hours. They should only be used when needed and carried wherever you go in case of emergency.

There are two classes of drugs used for short-acting bronchodilators: beta-agonists, which bind to receptors in the lung to stop spasms, and anticholinergics, which blocks that chemicals that trigger spasms.

The short-acting beta agonists (SABAs) currently approved in the U.S. are:

  • Albuterol
  • Xopenex (levalbuterol)
  • Metaproterenol
  • Terbutaline

The short-acting anticholinergic currently approved in the U.S. is:

  • Atrovent (ipratropium)

There is also a combination inhaled formulation called Combivent which contains ipratropium and the short-acting beta-agonist albuterol.

Long-Acting Bronchodilators

Persons with advanced COPD are often prescribed inhaled medications that are taken every day whether they have symptoms or not. These drugs are referred to as long-acting bronchodilators.

Individuals at high risk of exacerbations can benefit from these drugs as they provide blanket protection for anywhere from 12 to 24 hours. As with short-acting bronchodilators, they contain either a beta-agonist or anticholinergic drug.

The long-acting beta agonists (LABAs) currently approved in the U.S. are:

  • Salmeterol
  • Performomist (formoterol)
  • Bambuterol
  • Indacaterol
  • Brovana (arformoterol)

The long-acting anticholinergics approved in the U.S. are:

Inhaled Steroids

People with severe COPD may not respond as well to long-acting bronchodilators and will often need an additional "boost" to maintain respiratory function. For these individuals, inhaled steroids may be used.

Inhaled steroids, also known as inhaled glucocorticoids, have a strong anti-inflammatory effect and can quickly reduce the swelling and production of mucus in the airways. They function in the same way as oral steroids but work faster and significantly reduce the risk of flare-ups and hospitalization. They are commonly used twice daily and often require a two-week "loading period" before they take full effect.

The inhaled steroids commonly used to treat COPD are:

  • Pulmicort (budesonide)
  • Aerospan (flunisolide)
  • Flovent (fluticasone)
  • Asmanex (mometasone)
  • QVAR (beclomethasone)

There are also three combination formulations that incorporate inhaled steroids:

  • Symbicort (formoterol and budesonide)
  • Advair (salmeterol and fluticasone)
  • Brio Ellipta (vilanterol and fluticasone)

The side effects of inhaled steroids tend to be less profound than those of oral or injected steroids. They may include a sore mouth or throat, hoarseness (dysphonia), and oral candidiasis (thrush). Long-term use is associated with an increased risk of glaucoma and osteoporosis.

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Article Sources

  • Vestbo, J.; Hurd, S.; Agusti, A. et al. "Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary." Am J Respir Crit Care Med. 2013; 187(4):347-65. DOI: 10.1164/rccm.210204-0596PP.