Why Are Mucolytics Beneficial for Patients with COPD?
Part of the clinical picture of chronic obstructive pulmonary disease (COPD) includes mucus hypersecretion in the airways and its impaired clearance, resulting in a chronic productive cough. Mucus production requires management, just like dyspnea and cough. But what can be expected from mucolytic treatment?
3 Phenotypes of COPD with Increased Mucus Production
The Czech Pneumological and Phthisiological Society (ČPFS) more than 10 years ago established phenotype characteristics for six basic types of COPD, for which they recommend individualized treatment. A significant part of the symptoms of three of these types is increased mucus production. These include the bronchitic phenotype, the frequent exacerbation phenotype, and the phenotype of the overlap between COPD and bronchiectasis. A rational part of the treatment should therefore be the use of mucoregulatory or mucolytic agents, sometimes collectively referred to as mucolytics.
Suppression and Prevention of Exacerbations
Approved mucolytics for this indication include erdosteine, carbocysteine, and N-acetylcysteine (NAC). According to recent data, ideal candidates for this treatment are patients with moderate COPD (FEV1 50–79%). Regular use of mucolytics is also included in the official GOLD recommendations, stating that in individuals with COPD not treated with inhaled corticosteroids (ICS), mucolytics can reduce the occurrence of exacerbations and slightly improve health status.
The Only Mucolytic Suitable for Combination with ICS
According to these recommended guidelines, erdosteine is the only one of the named trio of drugs that can significantly affect the occurrence of exacerbations regardless of whether patients are concurrently using ICS. This statement is important for practice because the recommended routine treatment of COPD practically always and across all phenotypes includes a combination of inhaled bronchodilators, often including ICS.
Severe Impact of Exacerbations
It is also very important to emphasize the prevention of exacerbations. A fundamental cornerstone of COPD treatment remains that exacerbations have a profound negative impact on the course of the disease, as they lead to accelerated decline in lung function, worsening health status, and increasing the risk of hospitalizations and death, and they also have a significant impact on the healthcare system.
International guidelines recommend the use of oral mucolytics to reduce the occurrence of COPD exacerbations in patients with moderate to severe airway obstruction and exacerbations despite optimal inhalation therapy.
Be Cautious with Antibiotics
Thiol-based mucolytics also have antioxidant, anti-inflammatory, and antimicrobial effects, which can contribute to their diverse clinical effects. Moreover, erdosteine and NAC can enhance the efficacy of certain classes of antibacterial agents. In practice, however, it is necessary to inform the patient to maintain a two-hour interval when concurrently taking NAC and antibiotics.
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Sources:
1. Fabiánová J. Recommendations for Mucolytic Treatment in COPD Patients – Expert Consensus. Farmakoterapie 2021; 1: 20–22. Kos S. Commentary on the Study. Farmakoterapie 2021; 1: 22.
2. Zatloukal J., Brat K., Neumannová K. et al. Chronic obstructive pulmonary disease – diagnosis and management of stable disease; a personalized approach to care, using the treatable traits concept based on clinical phenotypes. Position paper of the Czech Pneumological and Phthisiological Society. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020 Dec; 164 (4): 325–356, doi: 10.5507/bp.2020.056.
3. GOLD 2021 report. Available at: https://goldcopd.org/2021-gold-reports
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