Approach to COPD: Respiratory or Systemic Treatment? Systemic Approach

According to GOLD guidelines, the only treatment that affects chronic obstructive pulmonary disease (COPD) development and progression is smoking cessation. Despite the inflammatory nature of COPD, none of the existing medications have been shown to modify the long-term decline in lung function that is the hallmark of the disease. Therefore, the goals of COPD management include relief of symptoms, prevention of disease progression, improvement of exercise tolerance and quality of life, together with prevention and management of exacerbations. Smoking cessation is the most effective intervention to reduce the risk of the development and progression of COPD and to reduce mortality. Pharmacotherapy (nicotine replacement, buproprion/nortryptiline and/or varenicline) may help patients stop smoking. Inhaled beta2 agonists and/or anticholinerigcs are central to pharmacologic management in COPD, particularly long acting beta2 agonists (LABA) and anticholinergic (LAMA), to prevent/reduce symptoms and prevent exacerbations. Non-pharmacologic treatments include rehabilitation, oxygen therapy, and surgical interventions. The diagnosis, assessment of severity and treatment of COPD may be greatly affected by the presence of comorbid conditions. Therefore, lung function measurement, non-invasive assessment of left ventricular function and/or glycaemia, may be useful to identify these comorbidities in these patients. Similarly, smoking prevention and cessation, weight control and diet, and exercise and rehabilitation all have the potential to beneficially affect not only COPD but also its comorbidities. Pharmacological treatment of COPD chronic comorbidities is more complex, as drugs are usually developed for single diseases or organs. Interestingly, a lot can be learnt from other chronic conditions, e.g. diabetes: glucose control with insulin and/or oral anti-diabetic agents not only controls diabetes but also prevents and contributes to treating systemic effects and comorbidities of diabetes, particularly cardiovascular diseases. More recently, drugs used for the treatment of hypertension, chronic heart failure, or lipid disorders, have been shown to have unexpected beneficial effects in COPD patients. Statins, which are used primarily as lipid-lowering agents, have potent anti-inflammatory properties also in the lung, have been shown to positively affect chronic comorbidities of metabolic syndrome, e.g. chronic heart failure, vascular diseases and COPD. beta-blockers, which are considered to be life-saving drugs in chronic heart failure, have also been recently shown to provide benefits in COPD patients. Beneficial effects have been reported for ACE inhibitors, and angiotensin receptor blockers. On the other side, drugs specifically developed and used to treat COPD may have significant beneficial effects on cardiovascular diseases and other common chronic comorbidities of COPD.