Day and Night Control of COPD and Role of Pharmacotherapy: A Review

Abstract

Alberto Braghiroli,1 Fulvio Braido,2 Alessio Piraino,3 Paola Rogliani,4 Pierachille Santus,5 Nicola Scichilone6 1Department of Pulmonary Rehabilitation, Sleep Laboratory, Istituti Clinici Scientifici Maugeri, IRCCS, Veruno, NO, Italy; 2Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genoa, Azienda Policlinico IRCCS San Martino, Genoa, Italy; 3Respiratory Area, Medical Affairs Chiesi Italia, Parma, Italy; 4Respiratory Unit, Department of Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy; 5Pierachille Santus, Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Milan, Italy; 6Department of Biomedicine and Internal and Specialistic Medicine (DIBIMIS), University of Palermo, Palermo, ItalyCorrespondence: Fulvio BraidoDepartment of Internal Medicine, IRCCS San Martino Genoa University Hospital, Genoa, ItalyEmail [email protected]: The topic of 24-hour management of COPD is related to day-to-night symptoms management, specific follow-up and patients’ adherence to therapy. COPD symptoms strongly vary during day and night, being worse in the night and early morning. This variability is not always adequately considered in the trials. Night-time symptoms are predictive of higher mortality and more frequent exacerbations; therefore, they should be a target of therapy. During night-time, in COPD patients the supine position is responsible for a different thoracic physiology; moreover, during some sleep phases the vagal stimulation determines increased bronchial secretions, increased blood flow in the bronchial circulation (enhancing inflammation) and increased airway resistance (broncho-motor tone). Moreover, in COPD patients the circadian rhythm may be impaired. The role of pharmacotherapy in this regard is still poorly investigated. Symptoms can be grossly differentiated according to the different phenotypes of the disease: wheezing recalls asthma, while dyspnea is strongly related to emphysema (dynamic hyperinflation) or obstructive bronchiolitis (secretions). Those symptoms may be different targets of therapy. In this regard, GOLD recommendations for the first time introduced the concept of phenotype distinction suggesting the use of inhaled corticosteroids (ICS) particularly when an asthmatic pattern or eosiophilic inflammations are present, and hypothesized different approaches to target symptoms (ie, dyspnea) or exacerbations. Pharmacotherapy should be evaluated and possibly directed on the basis of circadian variations, for instance, supporting the use of twice-daily rapid-action bronchodilators and evening dose of ICS. Recommendations on day and night symptoms monitoring strategies and choice of the specific drug according to patient’s profile are still not systematically investigated or established. This review is the summary of an advisory board on the topic “ 24-hour control of COPD and role of pharmacotherapy”, held by five pulmonologists, experts in respiratory pathophysiology, pharmacology and sleep medicine.Keywords: COPD, symptoms, dyspnea, night, sleep, follow-up, adherence, circadian LAMA, LABA, ICS

Keywords

• copd – symptoms – dyspnea – night – sleep – follow-up – adherence – circadian lama – laba – ics