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Chronic obstructive pulmonary disease Useful medications for patients with recurrent symptoms

机译：慢性阻塞性肺病具有复发症状患者的有用药物

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Chronic obstructive pulmonary disease (COPD) is a respiratory disorder characterised by largely irreversible changes in air flow due to irritants such as tobacco smoke. Patients with COPD experience acute exacerbations. Severe disease may progress to chronic respiratory failure. We reviewed the literature on basic medications available for COPD, using the standard Preserve methodology. There are few clinical data on treatment of mild COPD. Regular medication is not necessary for patients who do not have recurrent symptoms. Eliminating exposure to cigarette smoke and other irritants such as workplace irritants, is the only measure known to improve the outcome of COPD. Evaluation of inhaled short-acting beta-2 agonists is based mainly on short-term trials. These drugs have been shown to improve dyspnoea. Salmeterol and formoterol, two long-acting beta-2 agonists, have been extensively evaluated in symptomatic patients. Compared with no treatment, these drugs reduce breath-lessness and acute exacerbations, preventing about two hospital admissions per 100 patients with moderate to severe COPD treated for 7 months. Indacaterol and olodaterol do not have a better harm-benefit balance. Inhaled beta-2 agonists occasionally provoke cardiovascular disorders. No excess mortality has been reported among the thousands of COPD patients included in clinical trials. There is little evidence that ipratro-pium, an inhaled short-acting anti-muscarinic bronchodilator, improves COPD symptoms. A risk of increased mortality among COPD patients treated with ipratropium cannot be ruled out. Tiotropium, an inhaled long-acting antimuscarinic bronchodilator, has been extensively evaluated in COPD. Tiotropium has symptomatic efficacy in COPD, reducing dyspnoea and acute exacerbations. Tiotropium had no tangible advantages over long-acting beta-2 agonists in seven randomised trials including more than 12 000 patients. Glycopyrronium and aclidinium, two other inhaled long-acting antimuscarinics, do not appear to be more effective. Tiotropium, like other inhaled antimuscarinics, has antimuscarinic adverse effects including cardiac, visual and buccal disorders. Glycopyrronium may carry a higher risk of serious cardiovascular effects. Combination of an antimuscarinic with an inhaled beta-2 agonist improves symptoms in 7% to 10% of patients. In patients with one or two COPD exacerbations per year, adding an inhaled corticosteroid (beclometa-sone, budesonide or fluticasone) to a long-acting beta-2 agonist prevents about 1 exacerbation during 3 to 4 years of treatment. Inhaled corticosteroids can cause pneumonia, candidiasis, dysphonia and adrenal insufficiency. Fluticasone seems to have more adverse effects than other inhaled corticosteroids. Theophylline has uncertain efficacy on symptoms of COPD. This drug has a narrow therapeutic index and carries a risk of serious adverse effects. It should not be used in COPD. Long-term treatment with roflumi-last or oral corticosteroids has an unfavourable harm-benefit balance in COPD. 9 In practice, in 2016, the first measure in COPD is to eliminate exposure to the irritant, most often tobacco. Drugs used in COPD have only modest, mainly symptomatic efficacy. Treatment should be adapted to symptoms and the frequency of exacerbations: a short-acting beta-2 agonist should be tried first, then replaced by an inhaled long-acting bronchodilator, or possibly tiotropium, when its effect is too short-lived. An inhaled cortico-steroid can be added if symptoms persist or exacerbations are frequent.
机译：慢性阻塞性肺疾病（COPD）是一种呼吸系统疾病，其特征是由于烟草烟雾等刺激物导致气流发生不可逆的变化。COPD患者经历急性加重。严重的疾病可能发展为慢性呼吸衰竭。我们使用标准保存方法回顾了有关COPD基础药物的文献。关于轻度COPD的治疗，临床资料很少。没有复发症状的患者无需定期服药。消除香烟烟雾和其他刺激物（如工作场所刺激物）的暴露，是已知的改善COPD预后的唯一措施。吸入短效β-2激动剂的评估主要基于短期试验。这些药物已被证明能改善呼吸困难。沙美特罗和福莫特罗是两种长效β-2激动剂，已在有症状的患者中得到广泛评估。与不治疗相比，这些药物减少了呼吸困难和急性加重，每100名接受7个月治疗的中重度COPD患者中约有两名患者住院。吲达卡特罗和奥洛代特罗没有更好的利弊平衡。吸入β-2激动剂偶尔会引发心血管疾病。在纳入临床试验的数千名慢性阻塞性肺病患者中，没有报告有过多的死亡率。几乎没有证据表明，一种吸入的短效抗毒蕈碱支气管扩张剂依普拉特罗-匹姆能改善COPD症状。不能排除使用异丙托品治疗的COPD患者死亡率增加的风险。噻托溴铵是一种吸入式长效抗霉素支气管扩张剂，已被广泛用于COPD。噻托溴铵对COPD有症状疗效，可减少呼吸困难和急性加重。在包括12000多名患者在内的七项随机试验中，噻托溴铵与长效β-2激动剂相比没有明显优势。另外两种吸入式长效抗霉素药物甘吡隆和阿克利定似乎没有更有效的效果。噻托溴铵和其他吸入性抗霉素药物一样，具有抗霉素副作用，包括心脏、视觉和口腔疾病。糖吡咯烷酮可能具有更高的严重心血管效应风险。在7%到10%的患者中，抗美沙林药物与吸入β-2激动剂联合使用可改善症状。对于每年有一到两次COPD加重的患者，在长效β-2激动剂中添加吸入性皮质类固醇（倍氯米塔松、布地奈德或氟替卡松）可在3到4年的治疗期间防止约1次加重。吸入皮质类固醇可导致肺炎、念珠菌病、发音困难和肾上腺功能不全。氟替卡松似乎比其他吸入性皮质类固醇有更多的不良反应。茶碱对COPD症状的疗效尚不确定。这种药物的治疗指数很窄，有严重不良反应的风险。它不应该用于慢性阻塞性肺病。长期使用罗氟米拉司特或口服皮质类固醇治疗对COPD患者的利弊平衡不利。9实际上，在2016年，COPD的第一项措施是消除对刺激物的接触，最常见的是烟草。慢性阻塞性肺病（COPD）患者使用的药物疗效有限，主要是症状疗效。治疗应根据症状和病情恶化的频率进行调整：应先试用短效β-2激动剂，然后在药效过短时，用吸入长效支气管扩张剂或噻托溴铵替代。如果症状持续或经常恶化，可以添加吸入皮质激素。

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    《Prescrire international》 |2016年第176期|共2页
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