Pharmacological therapy in COPD patients is used to reduce symptoms, reduce the frequency and severity of exacerbations, and improve exercise tolerance and health status.²

Long-acting muscarinic antagonists (LAMAs) like tiotropium bromide may be used as a first-line treatment in patients with moderate to severe disease.³ Tiotropium bromide may be used as monotherapy and in combination with long-acting beta² agonists (LABAs).³ In most comparative studies of tiotropium and placebo, ipratropium or salmeterol, tiotropium provided significant beneficial effects on lung function, including improvements in FEV1 (forced expiratory volume in one second) and FVC (forced vital capacity).³

In SA, tiotropium bromide is indicated for the long-term maintenance treatment of COPD, including chronic bronchitis and chronic bronchitis associated with emphysema.⁴ It has a slow onset of peak bronchodilation, but a 24-hour duration of action facilitating once-daily administration.^4,5 With over 10 years' prescribing history and 50 million patient-years of use, tiotropium has the benefit of a more extensive clinical evidence base relative to other long-acting bronchodilators, with demonstrated efficacy and safety
in COPD.⁶

BRONCHODILATORS

The 2022 update of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy document highlights the following strong evidence regarding the use of bronchodilators in patients with stable COPD:²

• Both LABAs and LAMAs significantly improve lung function, dyspnoea, health status and reduced exacerbation rates
• LAMAs have a greater effect on exacerbation reduction compared with LABAs and have decreased hospitalisations
• Combination treatment with LABA and LAMAs increases the FEV1 and reduces symptoms compared to monotherapy
• Tiotropium bromide improves the effectiveness of pulmonary rehabilitation in increasing exercise performance.

PULMONARY REHABILITATION

Pulmonary rehabilitation is a core component in the management of patients with moderate to severe COPD, and includes patient tailored therapies (exercise training, education and behaviour change), which are designed to improve the physical and psychological condition of patients.⁷ Pulmonary rehabilitation has been shown to reduce the symptoms of anxiety and depression, reduce hospitalisation in patients with recent exacerbations, and improve health status and exercise tolerance in stable patients.²

THE LOCAL SITUATION

Cape Town has the highest prevalence of stage 2 COPD (19% overall, 22% male and 17% female).⁵ Smoking is a major cause of COPD and additional factors such as HIV infection, exposure to biomass fuels and tuberculosis (TB) points to a high prevalence of COPD in SA, which is expected to rise over the next few years.⁵

The prospect of an affordable tiotropium generic may be of value to COPD patients in lower to middle income countries (LMICs) like SA. LMICs face many research challenges such as lack of human resources, planning and finance and technology limitations.¹ Therefore, the support of higher income countries (HICs) and active participation in ongoing research with HICs, is critical to improve the understanding and management of COPD in LMICs.¹

REFERENCES:

1. Vu G, Ha G, Nguyen C, Vu G, Pham H, Latkin C et al. Interventions to Improve the Quality of Life of Patients with Chronic Obstructive Pulmonary Disease: A Global Mapping During 1990–2018. International Journal of Environmental Research and Public Health. 2020;17(9):3089.
2. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (2022 Report) [Internet]. 2022 p. 48, p. 51, p 92. Available from: https://goldcopd.org/wp-content/uploads/2021/12/GOLD-REPORT-2022-v1.1-22Nov2021_WMV.pdf
3. Anzueto A, Miravitlles M. Tiotropium in chronic obstructive pulmonary disease – a review of clinical Development. Respiratory Research (2020) 21:199
4. Drug approval package insert- Professional Information for Tiores
5. Abdool-Gaffar et al. Management of chronic obstructive pulmonary disease—A position statement of the South African Thoracic Society: 2019 update. J Thorac Dis 2019;11(11):4408-4427.
6. Halpin DM, Kaplan AG, Russell RK. Why choose tiotropium for my patient? A comprehensive review of actions and outcomes versus other bronchodilators. Respir Med. 2017 Jul;128:28-41
7. Spruit et al. An Official American Thoracic Society/European Respiratory Society Statement: Key Concepts and Advances in Pulmonary Rehabilitation2013. Am J Respir Crit Care Med 188(8): e13-64.
8. Murphy, P.B.; Rehal, S.; Arbane, G.; Bourke, S.; Calverley, P.M.A.; Crook, A.M.; Dowson, L.; Du_y, N. Gibson, G.J.; Hughes, P.D.; et al. Effect of Home Non-invasive Ventilation With Oxygen Therapy vs Oxygen Therapy Alone on Hospital Readmission or Death After an Acute COPD Exacerbation: A Randomized Clinical Trial. JAMA 2017, 317, 2177–2186. ncbi.nlm.nih.gov/pmc/articles/PMC5710342/?report=printable