Some inhalers combine a long-acting beta2-agonist and a corticosteroid (such as Advair, Seretide, and Symbicort). However, recent research is questioning whether adding inhaled corticosteroids to inhaled long-acting beta agonists has any significant benefit. The combination does not have a major impact on the number of severe COPD exacerbations or mortality.
Side Effects. Side effects of both long- and short-acting beta2-agonists include anxiety, tremor, restlessness, and headaches. Patients may experience fast and irregular heartbeats. A physician should be notified immediately if such side effects occur, particularly in people with existing heart conditions. Such patients face an increased risk of sudden death from heart-related causes. This risk is higher with medications taken by mouth or through nebulizers, but there have also been reports of heart attacks and chest pain (angina) in some patients using inhaled beta2-agonists.
Loss of Effectiveness and Overdose. There has been some concern that short-acting beta2-agonists may become less effective when taken regularly over time, increasing the risk of overuse. The degree to which this affects the airways is uncertain. In some studies, these drugs became less effective with longer use. However, the peak effect appears to remain, making these drugs still useful for attacks. Regular use of long-acting beta2-agonists may reduce the effectiveness of short-acting forms.
A major concern is that patients who perceive beta2-agonists as being less effective may overuse them. Overdose can be serious and, in rare cases, even life threatening, particularly in patients with heart disease or asthma.
Corticosteroids
Corticosteroids are powerful anti-inflammatory drugs.
Oral Corticosteroids. Oral corticosteroids are reserved for treating COPD exacerbations, and research finds that they are better than inhaled corticosteroids for this purpose. They speed the time to recovery and reduce the length of the hospital stay, but they do not reduce mortality or affect the long-term progression of the disease. They shouldn't be regularly used for stable disease because of the increased risk of side effects.
Inhaled Corticosteroids. Inhaled corticosteroids (ICS) are the mainstay of asthma therapy. However, their use in COPD is controversial. During the first 6 months of use, ICS may improve lung function. After 6 months, lung function begins to decline again. Although inhaled corticosteroids can help prevent COPD exacerbations, the benefits may not be as significant as was once thought. In one analysis of studies, the benefit was only noted in patients with a FEV1 of less than 50% of predicted.
There has been some concern that ICS might increase the risk of developing and dying from pneumonia in patients with COPD. However, recent evidence has not shown pneumonia to be a risk.
Theophylline and Other Methylxanthines
Methylxanthines (primarily slow-release theophylline) are also bronchodilators, which relax the airways of the lungs. These drugs are used in patients with more severe exacerbations that do not respond completely to corticosteroids, oxygen, or antibiotics.
These drugs do not significantly improve lung function, symptoms, or overall outcomes when used for acute exacerbations. Some experts believe that the modest benefits do not outweigh the risk of toxic side effects from these drugs. Side effects are generally related to the amount of theophylline in the blood, and can include:
- Abdominal pain
- Anxiety
- Diarrhea
- Excess urination (diuresis)
- Irregular heartbeat (arrhythmia) and palpitations
- Headache
- Heartburn
- Insomnia
- Loss of appetite
- Nausea
- Reflux
- Restlessness
- Seizures
- Tremor
- Vomiting
Administering Inhaled Drugs
Previous Section
Review Date: 04/10/2010
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine,
Harvard Medical School; Physician, Massachusetts General Hospital.
Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M.,
Inc.
A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org)
