Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 64-year-old woman is evaluated during a posthospital visit for severe COPD with an FEV1 of 30% of predicted. She has been admitted three times during the last year with acute exacerbations characterized by cough, increased purulent sputum production, and dyspnea. She is now at baseline of her exertional dyspnea and has no cough. She has already participated in a pulmonary rehabilitation program. She currently takes tiotropium, budesonide/formoterol, and albuterol.
On physical examination, vital signs are normal. Oxygen saturation is 90% on 3 L/min of supplemental oxygen at rest and with exertion. Pulmonary examination reveals decreased breath sounds throughout. The remainder of the examination is noncontributory.
Which of the following is the most appropriate treatment to reduce this patient’s COPD exacerbations?
A. Chronic low-dose oral glucocorticoid
B. Chronic macrolide therapy
C. Increase supplemental oxygen
D. Nebulized hypertonic saline
MKSAP Answer and Critique
The correct answer is B. Chronic macrolide therapy.
The most appropriate guideline-recommended (grade 2A) treatment of this patient with severe COPD and frequent exacerbations is chronic macrolide therapy. Macrolide antibiotics have inflammatory and antimicrobial effects and may reduce the frequency of exacerbations when used long-term by patients with severe COPD. Several clinical trials to assess prophylactic use and benefit have demonstrated a reduction in the rate of exacerbation in patients with moderate to severe COPD with one or more moderate or severe exacerbations in the previous year despite optimal maintenance inhaler therapy. The duration and exact dosage of macrolide therapy are unknown. The primary concerns with long-term macrolide therapy are development of antibiotic resistance, including macrolide-resistant strains of nontuberculous mycobacteria. In addition, hearing loss and potentially fatal arrhythmias due to prolongation of the QT interval have occurred in association with azithromycin.
The long-term use of systemic glucocorticoids is avoided in the chronic management of COPD due to lack of demonstrated benefit and recognized increased risk of significant side effects such as diabetes, hypertension, muscle weakness, and decreased functional status.
The use of supplemental oxygen in patients with COPD and hypoxemia has been shown to improve quality of life and mortality in patients who have resting hypoxemia with an arterial PO2 of 55 mm Hg (7.31 kPa) or lower, or oxygen saturation on pulse oximetry (Spo2) of 88% or lower. This patient’s Spo2 is above 88% at rest and on exertion on her current level of supplemental oxygen. Increasing this further has not been shown to decrease the rate of acute exacerbations.
Mucolytics such as nebulized hypertonic saline and airway clearance maneuvers may provide some symptomatic relief in patients with significant sputum production, but this patient does not have cough or sputum production. Moreover, these interventions have not been shown to decrease the rate of acute exacerbations in patients with COPD.
Key Point
- In patients with severe COPD and frequent exacerbations, chronic macrolide therapy has been shown to decrease COPD exacerbations.
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