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COPD: Medications and Other Therapies

for Health Care Providers

Table 2: Medications and Other Therapies

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Beta-adrenergic agonists (albuterol, levalbuterol, pirbuterol)
  • Mainstay of therapy
  • eg, albuterol via nebulizer (2.5 mg) or metered-dose inhaler (MDI) (180 mcg [2 puffs]) Q2H
Anticholinergic bronchodilators (ipratropium, glycopyrrolate)
  • In addition to beta-agonists
  • eg, ipratropium via nebulizer (500 mcg) or MDI (34 mcg [2 puffs]) Q4H
Glucocorticoids
  • Methylprednisolone 60-125 mg IV Q6-12H, or prednisone 40 mg PO QD
  • Treat for up to 14 days; studies show good outcomes with 9 days of treatment
  • Studies show no difference in outcomes between taper vs abrupt cessation of steroids in courses up to 14 days
Antibiotics
  • Controversial; studies do not show convincing benefit over placebo
  • May consider for patients with increased sputum purulence AND increased sputum volume OR for patients with increased dyspnea alone
  • For patients with severe exacerbations requiring mechanical ventilation (invasive or noninvasive)
  • Predominant bacteria include Haemophilus influenza, Streptococcus pneumoniae, and Moraxella catarrhalis
  • For uncomplicated patients (FEV1>50%, no antibiotics in past 3 months, <3 exacerbations in last year): doxycycline, TMP-SMX, 2nd or 3rd generation cephalosporin, or extended-spectrum macrolide
  • For complicated patients (cardiac disease, FEV1<50%, antibiotics in past 3 months, ≥3 exacerbations in past year): amoxicillin + clavulanate or fluoroquinolone
  • Treat for 7-10 days
Theophylline
  • Initial dosage of 400-600 mg/day (long-acting formulation), with target blood level of 5-12 mcg/mL
Oxygen therapy
  • By nasal cannulae, Venturi masks, non-rebreather masks
  • Titrate to target pulse oxygen >90% or PaO2 >60-65 mmHg
Noninvasive positive pressure ventilation (NIPPV) in hospitalized patients
  • Such as bilevel positive airway pressure
  • Improves respiratory acidosis, decreases respiratory rate, severity of breathlessness, and length of hospital stay
  • Studies suggest that NIPPV may reduce mortality and the need for invasive ventilation
  • Consider in moderate to severe exacerbations with acidemia (pH ≤7.35) and increased work of breathing (eg, RR >25); also in patients with PaCO2 above baseline (note that patients with COPD may have stable chronic elevation in PaCO2); compare acute value with baseline

From Chronic Obstructive Pulmonary Disease
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009