operate machines be cautious with the use in patients with narrow-angle glaucoma, benign prostatic hyperplasia and myasthenia gravis contraindications allergic to atropine long-acting beta2-agonist (laba) formoterol salmeterol indacaterol olodaterol refer to saba side effects and contraindications refer to saba more preferred in regular treatment very long duration of action (12–24 hours) huge improvement in lung function and symptoms risk of exacerbation greatly lowered → lama more prominent than laba provided in inhalers → techniques for usage is important for management of copd caution should not be used in acute exacerbation for rapid relieve of symptoms long-acting muscarinic antagonist (lama) tiotropium aclidinium bromide glycopyrronium bromide umeclidinium refer to sama side effects and contraindications refer to sama caution should not be used in acute exacerbation for rapid relieve of symptoms methylxanthines theophylline aminophylline inhibit pdes in smooth muscle → reduce camp clearance → bronchodilation antagonize adenosine receptor → maintain sympathetic nervous system activity → bronchodilation methylxanthines also tackle inflammation but the exact mechanism is not clearly known side effects headache nausea / vomiting abdominal discomfort restlessness increased acid secretion arrhythmias at high dose narrow therapeutic range avoid drugs inducing / inhibiting cyp1a2 and cyp2e1 caution metabolised by cyp1a2 and cyp2e1 smoking can induce methylxanthine metabolism contraindications hypersensitivity to xanthines inhaled corticosteroid (ics) fluticasone beclomethasone budesonide mometasone act on airway smooth muscle cells by activating intracellular glucocorticoid receptor → modifying gene expression in the cells promote lipocortin production inhibit production of inflammatory factors by phospholipase a2 discourage biosynthesis of interleukin 1 (il-1) reduce inflammatory response side effects local dysphonia throat irritation and coughing oral thrush systemic less common dermal thinning not for monotherapy → commonly use in combination provided in inhalers → techniques for usage is important for management of copd rinsing mouth with water, gargle and spit the water out, together with using mdis with spacer can reduce oral thrush also act by enhancing the effect of beta2 agonists → correct and prevent the desensitization of beta2 receptors caution should not abruptly stopping treatment contraindications no known contraindications due to local action phosphodiesterase-4 (pde4) inhibitor roflumilast selectively blocking pde4 on airway smooth muscles → increase intracellular camp level → induce action of protein kinase a → modulate inflammatory cytokine biosynthesis → reduce inflammation side effects diarrhea nausea headache weight loss psychiatric disturbance → suicidal thoughts not for rapid relief of symptoms reduce risk of exacerbation improved lung function is observed caution metabolised by cyp3a4 and cyp1a2 patient with history of depression / suicidal thought /action should be carefully examined and weight the risk and benefit of the administration contraindications moderate to severe liver impairment mucolytics carbocisteine n-acetylcysteine cleavage of s-s disulphur bond interlinking mucin polymer in the mucus → thinning the mucus and easier to be coughed out side effects headache diarrhea stomach pains used in acute exacerbation beneficial to patients not having ics only caution history of stomach ulcers contraindications allergy to the active pharmaceutical product or any excipients inside active peptic ulcer systemic corticosteroids prednisone refer to ics side effects mostly related to long-term administration adrenocortical insufficiency fluid retention weight gain bone loss (osteoporosis) cataract diabetes used in acute exacerbation usually used for 5 days can be used orally or by intravascular injection it can be abruptly discontinued without any tapering caution should not abruptly stopping treatment contraindications systemic fungal infections more but not common in short term usage antibiotics amoxicillin / clavulanic acid macrolides tetracycline amoxicillin interact with penicillin-binding proteins → prevent peptidoglycan layer formation in the bacteria → bacteria lack of protection and burst due to water absorption clavulanic acid block beta-lactamase activity in bacteria → restore activity of penicillin-like antibiotics macrolides interact with 50-s subunit of the bacterial ribosome → stop bacterial protein synthesis tetracycline interact with ribosomal 30-s subunit of bacteria → prevent bacterial protein synthesis an image showing mechanism of action of antibiotics side effects for all antibiotics disturbance of gastrointestinal system (e.g. diarrhea and nausea) due to the effect on gut microflora. amoxicillin / clavulanic acid allergic reactions if allergic to penicillin macrolides skin rashes eosinophilia tetracyclines enamel dysplasia photosensitivity tooth discoloration used in acute exacerbation 5–7 days of treatment is considered risk of exacerbation can be lessen by regular use of macrolides only be used when the patient experience three cardinal symptoms of copd exacerbation: worsening dyspnea, increasing sputum production and purulence caution change to other type if allergic to specific type possible drug interactions avoid tetracycline when there is pre-existing renal or hepatic impairment dose adjustment needed for amoxicillin / clavulanic acid in patients with renal impairment contraindications pregnancy (for tetracycline) allergy combination inhalers an image of different types of inhalers. in patients with copd, multiple inhalers need to be used at a time. there are two major types of inhaler, namely dry-powder inhaler(dpi) and metered-dose inhaler(mdi), and many more subtypes with different techniques for using them. adherence is also an issue with the use of multiple inhalers. generally with different types of inhalers, the adherence will be lowered. proper inhaler technique and adherence are two of the factors that affect the management of copd. other factors include smoking cessation and participation in physical activities, to name but a few. with inappropriately applied inhaler technique and low adherence, there will be ineffective management of copd, thus increasing in the burden on the healthcare sector. as a result, inhalers combining multiple medications are invented to tackle the problem. medication combined examples benefits saba+sama salbutamol / ipratropium (mdi) the improvement in symptoms and fev1 is greater than the use of saba or sama alone laba+lama formoterol / aclidinium (dpi) formoterol / glycopyrronium (mdi) indacaterol / glycopyrronium (dpi) vilanterol / umeclidinium (dpi) olodaterol / tiotropium (respimat) lower rate of acute exacerbation when used in combination less symptoms and better improvement in lung function ics+lama formoterol / beclometasone (mdi / dpi) formoterol / budesonide (mdi / dpi) formoterol / mometasone (mdi) salmeterol / fluticasone propionate (mdi / dpi) vilanterol / fluticasone furoate (dpi) perform better than individual medication to improve lung function better health status is obtained compared to individual medications greater reduction in risk of exacerbation than ics or lama solely laba+lama+ics fluticasone / umeclidinium / vilanterol (dpi) beclometasone / formoterol / glycopyrronium (mdi) budesonide / formoterol / glycopyrrolate (mdi) better improvement of lung function and symptom obtaining better health status larger decline in exacerbation risk than all combined inhalers and lama.