start roflumilast for chronic bronchitis patient

The principal action of phosphodiesterase 4 inhibitors is to reduce inflammation by inhibiting the breakdown of intracellular cyclic adenosine monophosphate. Roflumilast is a once daily oral medication that reduces the frequency of moderate and severe exacerbations treated with systemic corticosteroids in patients with chronic bronchitis, severe to very severe COPD, and a history of exacerbations. The effects on lung function are noted when roflumilast is added to long-acting bronchodilators and in patients whose disease is not controlled with fixed-dose long-acting β-agonist (LABA) + inhaled corticosteroid (ICS) combinations. The beneficial effects of roflumilast have been reported to be greater in patients with a previous history of hospitalization for an acute exacerbation.

In patients treated with LABA + long-acting muscarinic antagonist (LAMA) + ICS (or those with an eosinophil count <100/µL [0.10 × 109/L]) still experiencing exacerbations, the following options may be considered to reduce the risk of exacerbations:

  1. Roflumilast may be considered in patients with FEV1 less than 50% predicted and chronic bronchitis, particularly if they have experienced at least one hospitalization for an exacerbation in the previous year (choice A is correct).
  2. Azithromycin may be considered in patients with moderate to severe COPD (FEV1 <80% predicted). Azithromycin use has been shown to produce a reduced exacerbation rate in former smokers only, although it has been associated with an increased incidence of bacterial resistance (choice B is incorrect).
  3. Withdrawal of ICS can be considered if pneumonia or other considerable side effects develop (choice C is incorrect). A study in which the investigators examined ICS withdrawal on a background of dual bronchodilator therapy demonstrated that both FEV1 loss and an increase in exacerbation frequency associated with ICS withdrawal was greatest among patients with a blood eosinophil count of 300/µL (0.30 × 109/L) or greater at baseline.

Blood eosinophil counts can help identify patients with a greater likelihood of a beneficial response to ICS. For patients with COPD and symptoms (COPD Assessment Test score ≥10) who have further exacerbations when using LABA + LAMA, and a blood eosinophil count of 100/µL (0.10 × 109/L) or greater, escalation to LABA + LAMA + ICS may be considered (choice D is incorrect).1

Footnotes

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