Table 9, Acute Exacerbation: Commonly Used Medications and Doses - Chronic Obstructive Pulmonary Disease

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Table 9Acute Exacerbation: Commonly Used Medications and Doses

Generic Name	Brand Names	Usual Adult Dose	Cost (30 days) ^a
Generic Name	Brand Names	Usual Adult Dose	Generic	Brand
Inhaled short-acting beta-2 agonists (SABA) [bronchodilator]
Albuterol HFA (90 mcg/puff)	ProAir, Proventil, Ventolin	4–8 puffs inhaled every 20 min x 4 h as needed, then 4–8 puffs inhaled every 1–4 h as needed	NA	$61 (all)
Albuterol nebulizer solution; either 0.083% ready to use (2.5 mg/3 mL) or 0.5% (2.5 mg/0.5 mL)		2.5–5 mg via nebulizer every 20 min x 3 doses, then 5–10 mg nebulized every 1–4 h as needed	$5	NA
Levalbuterol tartrate HFA (45 mcg/puff)	Xopenex	2 puffs inhaled every 4–6 h as needed	$10	$74
Levalbuterol nebulizer solution (1.25 mg/3 mL ready to use, or 1.25 mg/0.5 mL)	Xopenex	0.63–1.25 mg via nebulizer every 8 h as needed	$182	$320
Inhaled anticholinergic (short-acting muscarinic antagonist = SAMA) ^b [bronchodilator]
Ipratropium HFA (17 mcg/puff)	Atrovent	2–4 puffs inhaled every 6 h as needed	NA	$395
Ipratropium nebulizer solution (500 mcg/2.5 mL)	Atrovent	500 mcg via nebulizer every 6 h as needed	$18	NA
Oral corticosteroids ^c [anti-inflammatory]
Prednisone: 1, 2.5, 5, 10, 20, 50 mg tabs; 1 mg/mL liquid		40 mg/day for 5–7 days. Regimens may vary in dosage strength and duration	$6	$26
Prednisolone: 5 mg tabs; 1 mg/mL, 2 mg/mL 3 mg/mL, 4 mg/mL liquid		40 mg/day for 5–7 days. Regimens may vary in dosage strength and duration	$13	$35
Antibiotics ^d
Patients without risk factors for poor outcomes ^e (in order of preference)
Azithromycin 250, 500 mg tabs; 100, 200 mg/5 mL liquid	Zithromax	500 mg orally on day 1, then 250 mg orally daily on days 2–5	$8 (tab) $12 (liquid)	$63 (tab) $131 (liquid)
Cephalosporins (2^nd or 3^rd generation)
Cefdinir 300 mg caps; 125, 250 mg/5 mL liquid	Omnicef	300 mg orally twice daily	$60 (tab) $8 (liquid)	$276 (tab) $90 (liquid)
Cefpodoxime 100, 200 mg tabs; 100 mg/5 mL liquid	NA	200 mg orally twice daily	$480 (tab) $79 (liquid)	NA NA
Cefprozil 250, 500 mg tabs; 250 mg/5 mL liquid	NA	500 mg orally twice daily	$122 (tab) $60 (liquid)	NA NA
Doxycycline hyclate 100 mg tabs	Vibramycin capsule	100 mg orally twice daily	$38	$645
Doxycycline calcium 50 mg/5 mL liquid	Vibramycin syrup	100 mg orally twice daily	NA	$452
Trimethoprim/sulfamethoxazole 80/400, 160/800 mg tabs; 40/200 mg/5 mL liquid	Bactrim, Septra Sulfatrim (liquid)	160/800 mg (DS tablet) orally twice daily	$14 (all tabs) $240 (liq)	$104 NA NA (liq)
Patients with risk factors for poor outcomes ^e (no particular order)
Amoxicillin/clavulanate 250/125, 500/125, 875/125 mg tabs; 200/28.5 mg/5 mL, 400/57 mg/5 mL liquid	Augmentin	500 mg orally every 8 h or 875 mg orally every 12 h	$62 (tab) $20 (liq)	$208 (tab) $62 (liq)
Levofloxacin 250, 500, 750 mg tabs; 25 mg/mL liquid	Levaquin ^f	500 mg orally daily	$12 (tab) $17 (liq)	$973 (tab) $408 (liq)
Patients at risk for infection with Pseudomonas aeruginosa ^g (no particular order)
Levofloxacin 250, 500, 750 mg tabs; 25 mg/mL liquid	Levaquin	750 mg orally daily	$21	$1820

a

Cost = For brand drugs, Average Wholesale Price minus 10%. AWP from Red Book Online 5/11/17. For generic drugs, Maximum Allowable Cost plus $3 from BCBS of Michigan MAC List, 5/1/17. Prices calculated for 30-day supply unless otherwise noted.

b

Ipratropium is preferred for acute exacerbations. Tiotropium does not have acute bronchodilating properties.

c

Oral corticosteroids are not for general maintenance and should be weaned after treatment of the exacerbation.

d

Antibiotics are recommended for patients with increased sputum purulence plus either increased sputum volume or increased dyspnea. Duration is usually 3 to 7 days, depending on the agent and response to therapy.

e

Risk factors for poorer outcomes with narrower spectrum antibiotics include: age ≥ 65, FEV₁ < 50% predicted, ≥ 2 exacerbations/year, and presence of comorbid diseases. Consider broader spectrum antibiotics for these patients.

f

Fluoroquinolones have been associated with disabling and potentially irreversible serious adverse reactions that have occurred together, including tendinitis and tendon rupture, peripheral neuropathy, and CNS effects. Discontinue levofloxacin immediately and avoid the use of fluoroquinolones in patients who experience any of these serious adverse reactions.

g

Risk factors for Pseudomonas aeruginosa are:

Recent hospitalization
Frequent administration of antibiotics (4 courses over the past year)
Severe COPD exacerbations
Isolation of P. aeruginosa during a previous hospitalization or colonization during a stable period

From: Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease.

Chick DA, Grant PJ, Van Harrison R, et al.

Ann Arbor (MI): Michigan Medicine University of Michigan; 2020 Jul.

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