COPD: 5 Must-Know Updates

Aaron B. Holley, MD


July 24, 2019

4. Pulmonary Rehabilitation

It is well established that COPD is associated with breathlessness that affects activity levels. Furthermore, systemic inflammation and corticosteroid use contribute to muscle wasting and weight loss, worsening the functional decline associated with reduced lung function. Medications used to treat COPD target the lungs almost exclusively. All too often, the activity level limits are ignored by physicians.

Exercise is clearly associated with health improvements for the general population and those with COPD.[18] Pulmonary rehabilitation (PR) provides a targeted exercise program designed to optimize activity levels for those with COPD. Its benefits are well established, and for many, if not all, patients with COPD, completion of a PR program will improve functional capabilities far more than is possible with an inhaler. Barriers to referral and compliance have been well documented,[19] and a recently published review clarifies the relationship between poor financial reimbursement and PR availability.[20] Exercise is difficult for these patients, PR takes time, and compliance is poor. However, as physicians, we must be candid with our patients with COPD and emphasize the value from sustained exercise, ideally via a PR program.

5. The Death of Theophylline

Theophylline is one of the oldest COPD medications available. As newer inhalers and targeted therapies have come to market, theophylline has fallen out of favor with clinicians and guidelines. The tight therapeutic window (little difference between therapeutic and supratherapeutic levels) is also an issue, and side effects are common. Still, theophylline remains in the GOLD guidelines,[6] it's inexpensive, and there is evidence for its use and biologic plausibility.[21]

A large, randomized controlled trial published in JAMA studied the impact of low-dose theophylline on COPD outcomes.[22] Of note, the population enrolled had experienced AECOPD, and about 80% were receiving ICS/LABA/LAMA therapy. Adding low-dose theophylline did not reduce the rate of AECOPD compared with placebo. Outside of areas where cost and access to healthcare and drugs is problematic, the use of low-dose theophylline appears to be dead.

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