Chronic Obstructive Pulmonary Disease (COPD): Developments in Pharmacological Treatments

Abstract

The immediate goals of pharmacological management in chronic obstructive pulmonary disease (COPD) are to minimise symptoms and improve exercise performance. The longer-term goals are to reduce the future risk of exacerbations, lung function decline and mortality. It is now recognised that a subset of COPD patients have type 2 inflammation, which is identified by the presence of higher blood eosinophil counts (BEC). Individuals with higher BEC show a greater response to pharmacological interventions targeting type 2 inflammation, including inhaled corticosteroids and the monoclonal antibody, dupilumab. The use of BEC as a biomarker to guide pharmacological treatment has enabled a precision medicine approach in COPD. This article reviews recent advances in the pharmacological treatment of COPD, encompassing the optimum use of inhaled combination treatments and the evidence to support the use of the novel inhaled phosphodiesterase inhibitor ensifentrine and monoclonal antibodies in patients with COPD.

Fig. 1

GOLD recommendations for initial pharmacological treatment for COPD. CAT COPD assessment test, COPD chronic obstructive pulmonary disease, ICS inhaled corticosteroid, GOLD global initiative for chronic obstructive pulmonary disease, LABD long-acting bronchodilator, LAMA long acting muscarinic antagonist

Fig. 2

Triple therapy (ICS/LABA/LAMA) in the treatment of stable COPD, in comparison to LABA/LAMA therapy. BEC blood eosinophil count, COPD chronic obstructive pulmonary disease, CV cardiovascular, HRQoL health-related quality of life, ICS inhaled corticosteroid, GOLD global initiative for chronic obstructive pulmonary disease, LABD long-acting bronchodilator, LAMA long-acting muscarinic antagonist, T2 Type 2

Fig. 3

Pharmacological treatment for stable COPD. BEC blood eosinophil count, COPD chronic obstructive pulmonary disease, CV cardiovascular, HRQoL health-related quality of life, ICS inhaled corticosteroid, IL interleukin, GOLD global initiative for chronic obstructive pulmonary disease, T2 Type 2

Fig. 4

Ensifentrine as a Novel inhaled Nebulised COPD thErapy (ENHANCE-1 and -2). AUC area under the curve, COPD chronic obstructive pulmonary disease, E-RS EXACT- respiratory symptoms tool, FEV₁ forced expiratory volume in 1 second, HRQoL health-related quality of life, ICS inhaled corticosteroid, GOLD global initiative for chronic obstructive pulmonary disease, LABD long-acting bronchodilator, LAMA long-acting muscarinic antagonist, mMRC modified medical research questionnaire, RR risk ratio, SGRQ Saint George’s respiratory questionnaire, TDI transition dyspnoea index

Fig. 5

Blocking signalling via the IL-4Rɑ (dupilumab) in the treatment of stable COPD. ASM airway smooth muscle, COPD chronic obstructive pulmonary disease, FeNO fractional exhaled nitric oxide, FEV₁ forced expiratory volume in 1 second, HRQoL health-related quality of life, iNOS inducible nitric oxide synthase, IL interleukin, MUC5AC mucin 5AC