Spiriva® should not be First-Line for Mild COPD

New evidence will spark controversy over how to treat COPD patients with MILD disease.

About seven in 10 COPD patients have early disease with minimal symptoms. But meds are usually studied in moderate to severe COPD.

Now evidence suggests that Spiriva (tiotropium), a long-acting muscarinic antagonist (LAMA), may be beneficial for mild COPD.

It seems to improve lung function and avoid one exacerbation requiring antibiotics or oral steroids in about 10 patients over 2 years.

But it doesn’t reduce COPD hospitalizations in these patients…and LAMA inhalers cost at least $54/month.

Continue to emphasize smoking cessation to slow COPD progression…and ensure patients are up to date with flu and pneumococcal vaccines.

Advise starting with a short-acting bronchodilator as needed for mild, occasional COPD symptoms. Suggest salbutamol.

Point out that short-acting bronchodilators haven’t been shown to reduce exacerbations…even if they’re given as a combo or scheduled QID. Plus Combivent (salbutamol/ipratropium) costs about $31/inhaler.

Instead, suggest adding a LAMA to a PRN short-acting beta-agonist in patients with mild, persistent symptoms…more than one exacerbation per year…or any exacerbation that requires an ED visit or hospital stay.

Explain that Spiriva® has the most evidence for mild COPD. But if patients or payers prefer, it’s okay to use another LAMA…Incruse (umeclidinium), Seebri (glycopyrronium), or Tudorza (aclidinium).

Generally recommend saving inhalers with long-acting beta-agonists (Serevent, Anoro, etc) for moderate to severe COPD. These haven’t been studied in mild COPD…and all cost at least $50/month.

Suggest avoiding inhaled steroids for mild or moderate COPD…unless patients also have asthma. Steroids are linked to thrush, pneumonia, etc.