Chronic obstructive pulmonary disease (COPD) is the term used to describe a variety of lung diseases including emphysema and chronic bronchitis, which cause irreversible lung damage. There is no cure, so management is focused on relieving symptoms. Inhaled bronchodilators - both short-acting and long-acting are commonly used. Inhaled corticosteroids, mucolytics, and methylxanthines also have a role, as do oral steroids and antibiotics during acute exacerbations, and oxygen and nebulised therapy in patients with severe, chronic COPD.

Dosage regimen

* Inhaled short-acting beta2 agonists (salbutamol, terbutaline) are taken when required.

* Inhaled long-acting beta2 agonists (salmeterol, formeterol) are taken twice a day.

* Inhaled short-acting anticholinergics (ipratropium) are taken three or four times a day.

* Inhaled long-acting anticholinergics (tiotropium) are taken once a day.

* Mucolytics (carbocisteine, erdosteine, mecysteine) are taken in divided doses throughout the day.

* Methylxanthines (theophylline, aminophylline) are taken every 12 hours.

* Inhaled corticosteroids (beclometasone, fluticasone, budesonide) are taken twice a day.

Patient's knowledge of the medicine's use

* Beta2 agonists reduce breathlessness. The onset of action in COPD is slower than in asthma. Short-acting agents may be used when required, whereas long-acting agents should be used by individuals who remain symptomatic or who have two or more exacerbations in a year.

* Anticholinergics reduce breathlessness, bronchoconstriction and mucus secretion. Short-acting agents may be used when required, whereas long-acting agents may be used if the patient remains symptomatic or has had experienced two or more exacerbations in a year and a long-acting beta2 agonist has failed.

* Methylxanthines have a small bronchodilator effect and reduce inflammation. They should be used for patients requiring longer-term treatment but unable to use inhalers.

* Corticosteroids have an anti-inflammatory effect. Inhaled corticosteroids may be used in combination with a long-acting beta2 agonist for patients with moderate to severe COPD. A short course of oral steroids should be given if the increased breathlessness of an exacerbation interferes with daily activities.

* Mucolytics clear excess sputum to make breathing easier. They may be employed to reduce exacerbations in COPD patients who have a chronic cough.

Is the medicine working?

* Asking the following questions will show how effective drug treatment is, and the impact the condition has on the patient's life:

* Has your breathing improved?

* How often do you experience shortness of breath?

* Does COPD affect your social or family life?

* Do you sleep well at night?

Side effects

* Beta2 agonists commonly cause cramp, tachycardia, nervousness and tremor.

* Anticholinergics commonly cause a cough, a dry mouth, nausea and constipation.

* Methylxanthines commonly cause tachycardia, gastrointestinal disturbances, headache and palpitations.

* Corticosteroids can cause adrenal suppression (ensure the patient has a steroid card) and glaucoma. If the patient experiences hoarseness or candidiasis, advice them to rinse the mouth with water after use or to use a spacer.

* Mucolytics very rarely cause rashes and gastrointestinal bleeds.

Monitoring

* Beta2 agonists can cause severe hypokalaemia. Therefore plasma levels should be regularly checked.

* Methylxanthines have a narrow therapeutic index, so plasma levels need monitoring after therapy is started and at regular intervals thereafter. Make sure the patient can recognise the signs of toxicity (convulsions and arrhythmias), and knows to contact their doctor immediately if this happens.

* Ensure the patient can recognise the signs of an exacerbation, and has standby oral corticosteroids and antibiotics.

* If patients taking corticosteroids develop paradoxical bronchospasm they should immediately stop taking the drug and contact their doctor.

Lifestyle

* Encourage the patient to lose or increase weight (depending on the situation).

* Encourage smokers to stop smoking as this is an important factor in the progression of the disease. Patients on methylxanthines should be advised to not smoke at all, as it can cause considerable variations in plasma-theophylline concentrations.

* Pulmonary rehabilitation can be used to improve social and physical performance.

* Patients can also try psychotherapy, family therapy or counselling.

Uzma Chaudhry, Relief Pharmacist, Lloyds Pharmacy, Oxfordshire

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