Q: I'm an 83-year-old male with severe COPD [chronic obstructive pulmonary disease]. It's been getting progressively worse, to the point where I need to have constant oxygen and really have to work for each breath.
My drugs cost about $1,800 a month — much more than Medicare will cover. I am presently on 80 mg of Zocor daily for high cholesterol and four inhaled medications for my COPD: Symbicort 160/4.5 twice a day, Pulmicort 180 mcg twice a day, Combivent three times a day and Xopenex 1.25 mg in a nebulizer four times a day. I also take Lyrica 200 mg twice a day for muscle cramps and pain, and a bottle of Ensure Plus four times a day. When I develop infections I'm also prescribed expensive antibiotics.
I've become so hyper and restless at night that I'm usually not able to get more than a couple of hours of sleep. I have to sit up to sleep because of my leg and back pain, and when I'm awake my legs are so weak that I can hardly walk. I don't know what to do and am hoping you can recommend something to help me.
A: I truly wish I had a magic pill to give you, but I'm sorry to report that your COPD isn't going to go away. I do, however, see many problems with your current drug therapy that, if corrected, would likely ease many of your health problems, thus giving you a better quality of life, and also reduce your out-of-pocket health costs.
First, you should talk with the doctor treating your pulmonary condition about stopping the Ensure Plus immediately. This product is typically used to help people maintain or gain weight, as each 8-ounce bottle contains 50 grams of carbohydrates and 350 calories.
What's important for you to keep in mind is that when carbohydrates are metabolized in the body, a byproduct of the metabolization is carbon dioxide. Because of their impaired lung function, COPD patients have a very difficult time exchanging the carbon dioxide for oxygen, which dramatically increases their respiration rate. This causes the body to expend more energy, thus causing additional weight loss. I know that this must be miserable for you, and it's almost certainly the main reason that your COPD has gotten worse, not better. Stopping the Ensure Plus will improve your respiration and may even allow you to reduce or stop the oxygen supplementation.
In my judgment, the use of four different bronchodilators — formoterol, in combination with budesonide, a corticosteroid (Symbicort); albuterol and ipratropium (Combivent); and levalbuterol (Xopenex) — and an additional dose of budesonide (Pulmicort) is excessive. The bronchial tubes can only be dilated so far; after that, the extra drugs can't do any more and just cause the kinds of adverse events you're experiencing: insomnia, agitation, restlessness and a weak, washed-out feeling. What's more, the bronchodilators you're using all have short half-lives (four to eight hours), which in your case may be causing rebound bronchoconstriction that makes your breathing problems worse. They're also expensive.
I'd recommend that you talk with your doctor about switching to a bronchodilator that provides 24-hour relief such as Spiriva 18mcg HandiHaler. Using it each morning should last until the next morning — and without the rebound effects. As your breathing volume increases over time, your overall condition should improve.
Both Symbicort and Pulmicort contain corticosteroids, which I do not like to see used on a routine basis, as they then become less effective in crisis situations. In my practice, I recommend the use of the corticosteroids only as a last resort.
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