COPD Preparations (Inhaled)

Drug	Available Strength	Dosage	Remarks
Long-Acting Anticholinergics (Inhaled)			Adverse Reactions Respiratory effects (upper respiratory tract infection [URTI], bronchitis, sinusitis, pharyngitis); CV effects (chest pain, palpitation); CNS effects (headache, dizziness); GI effects (dry mouth, bad taste, dyspepsia, nausea, constipation, diarrhea); Hypersensitivity effects (urticaria, angioedema, rash, bronchospasm) Special Instructions Umeclidinium: Avoid in patients with severe milk-protein allergy Avoid contact of inhalation solution with eyes Use with caution in patients with prostatic hyperplasia, unstable ischemic heart disease, severe renal impairment, patients predisposed to narrow-angle glaucoma, bladder neck obstruction, urinary retention Check patient’s inhaler technique for optimum delivery of drug Glycopyrronium, Tiotropium, Umeclidinium: Not for initial treatment of bronchospasm
Aclidinium bromide	322 mcg/dose MDI/DPI	1 inhalation PO 12 hourly
Glycopyrronium bromide	50 mcg/dose breezhaler DPI	1 dose inhaled PO 24 hourly
Tiotropium bromide	18 mcg/dose HandiHaler DPI	1 dose inhaled PO 24 hourly at the same time each day
	18 mcg/dose rotahaler DPI	1 dose inhaled PO 24 hourly at the same time each day
	2.5 mcg/dose solution respimat inhaler	2 puffs PO 24 hourly at the same time each day
Umeclidinium	62.5 mcg/dose DPI	1 inhalation PO 24 hourly at the same time each day
Short-Acting Anticholinergic (Inhaled)
Ipratropium bromide	20 mcg/puff MDI	1-2 puffs PO 6-8 hourly Max dose: 12 puffs/day
	40 mcg/cap DPI	1 cap inhaled PO 6-8 hourly
	250 and 500 mcg/2 mL inhalation solution unit dose vial (UDV), 0.025% inhalation solution	1 UDV via nebulizer 6-8 hourly or 0.4-2 mL inhalation solution via nebulizer 6-8 hourly
Long-Acting Beta₂-Agonist Bronchodilators (Inhaled)
Arformoterol	15 mcg/2 mL solution	15 mcg inhaled via nebulization 12 hourly Max dose: 30 mcg/day	Adverse Reactions CV effects (angina, palpitation, chest pain, tachycardia); CNS effects (headache, irritability, seizure); Dermatologic effects (urticaria, rash); Endocrine effects (hyperglycemia, hypokalemia); Respiratory effects (dyspnea, bronchospasm, cough, viral infection); Other effects (anaphylaxis, allergy, pain, diarrhea) Special Instructions Use with caution in patients with hyperthyroidism, DM, myocardial infarction (MI), HF, arrhythmia, hypertension, glaucoma, hypokalemia, seizure disorder Monitor K levels Check patient’s inhaler technique for optimum delivery of drug
Formoterol	12 mcg/cap DPI	1-2 cap inhaled PO 12 hourly
Formoterol	20 mcg/2 mL solution	20 mcg inhaled via nebulization 12 hourly Max dose: 40 mcg/day
Indacaterol	150 and 300 mcg/cap breezhaler DPI	1 cap inhaled 24 hourly at the same time each day Max dose: 300 mcg/day
Olodaterol	2.5 mcg/puff solution for inhalation respimat inhaler	2 puffs PO 24 hourly at the same time each day
Salmeterol	25 mcg/puff MDI	2-4 puffs PO 12 hourly
Salmeterol	50 mcg/dose accuhaler DPI, diskhaler DPI	1-2 doses inhaled PO 12 hourly
Short-Acting Beta₂-Agonist Bronchodilators (Inhaled)¹
Fenoterol	100 mcg/puff MDI	1-2 puffs PO 6-8 hourly as required Max dose: 8 puffs/day	Adverse Reactions CV effects (angina, palpitation, chest pain, tachycardia); CNS effects (headache, irritability, seizure); Dermatologic effects (urticaria, rash); Endocrine effects (hyperglycemia, hypokalemia); Respiratory effects (bronchospasm, cough, viral infection); Other effects (anaphylaxis, allergy) Special Instructions Use with caution in patients with hyperthyroidism, DM, myocardial insufficiency,arrhythmia, hypertension, HF, glaucoma, hypokalemia, seizure disorder Monitor K levels Check patient’s inhaler technique for optimum delivery of drug
Fenoterol	1 mg/mL (0.1% inhalation solution)	0.5 mL (10 drops) via nebulizer up to 6 hourly
Levalbuterol (Levosalbutamol)	45 mcg/puff MDI	2 puffs PO 4-6 hourly
Levalbuterol (Levosalbutamol)	1.25 mg/3 mL inhalation solution	Initial dose: 0.63 mg via nebulizer 6-8 hourly May be increased if necessary to Max dose: 1.25 mg via nebulizer 6-8 hourly
Procaterol	10 mcg/puff swinghaler MDI	2 puffs PO up to 6 hourly
Salbutamol (Albuterol)	100 mcg/dose easi-breathe MDI	100-400 mcg inhaled PO 6-8 hourly as required
	100 mcg/puff MDI/CFC-free
	200 mcg/dose easyhaler DPI
	200 mcg/cap rotahaler DPI
	200 mcg/dose accuhaler DPI
	200 and 400 mcg/cap DPI
	200 mcg/dose diskhaler DPI
	1 mg/mL, 2.5 mg/2.5 mL, inhalation solution unit dose	2.5-5 mg via nebulizer 6-8 hourly as required
	5 mg/mL (0.5% solution) inhalation solution	0.5-1 mL via nebulizer 6-8 hourly
Terbutaline	500 mcg/dose turbuhaler DPI	500 mcg inhaled PO 6-12 hourly
Terbutaline	2.5 mg/mL	2.5-10 mg via nebulizer 6-12 hourly
Corticosteroids (Inhaled)
Beclomethasone dipropionate	50, 100, 250 mcg/puff MDI; 100, 250 mcg/puff easi-breathe	Children 6-11 years old: 100-400 mcg/day Adults and children ≥12 years old: 200-1,000 mcg/day	Adverse Reactions Local effects (cough from upper airway irritation, dysphonia, oropharyngeal candidiasis); Paradoxical bronchospasm Risk of systemic effects will depend on dose, potency of the corticosteroid, absorption from the gut, delivery system, the use of spacers and the drug’s pharmacokinetics Long-term use of high-dose steroids may result in cataracts, glaucoma, skin thinning, easy bruising and adrenal suppression Special Instructions Local effects may be minimized by using a spacer, gargling and spitting out with water Not for relief of acute bronchospasm Contraindicated in patients with recent nasal septal ulcers, surgery, or trauma Use with caution in patients with HF, acute MI, DM, GI diseases, hepatic/renal impairment, myasthenia gravis, osteoporosis, seizure disorder, thyroid disease
Beclomethasone dipropionate	200 mcg/dose easyhaler DPI
Budesonide	100, 200 mcg/puff MDI	Children 6-11 years old: 100-400 mcg/day Adults and children ≥12 years old: 200-800 mcg/day Nebules Children 6-11 years old: 250-1,000 mcg/day
	100, 200, 400 mcg/dose turbuhaler DPI; 100, 200, 400, 800 mcg/cap DPI
	250 mcg/mL, 500 mcg/mL, 500 mcg/2 mL, 1 mg/2 mL solution for inhalation unit dose
Fluticasone	50, 125, 250 mcg/puff MDI	Children 6-11 years old: 50-200 mcg/day Adults and children ≥12 years old: 100-500 mcg/day
	50, 100, 250 mcg/dose accuhaler DPI; 50, 250 mcg/dose rotadisk DPI; 50, 125, 250 mcg/dose evohaler
	0.5 mg/2 mL, 2 mg/2 mL solution for inhalation unit dose

¹Please note: Doses for acute exacerbations can be higher than the recommended maintenance doses listed here.

COPD Preparations

Long-Acting Beta₂-Agonist Bronchodilators (Oral)
Drug	Dosage	Remarks
Bambuterol	10-20 mg PO 24 hourly at bedtime	Adverse Reactions CV effects (angina, palpitation, chest pain, tachycardia); CNS effects (headache, irritability, seizure); Dermatologic effects (urticaria, rash); Endocrine effects (hyperglycemia, hypokalemia); Respiratory effects (bronchospasm, cough, viral infection); Other effects (anaphylaxis, allergy) Special Instructions Tulobuterol: Contraindicated in patients with pheochromocytoma Use with caution in patients with hyperthyroidism, DM, myocardial insufficiency, arrhythmia, hypertension, HF, glaucoma, hypokalemia, seizure disorder Monitor K levels
Salbutamol (Albuterol)	2-8 mg PO 6-8 hourly Extended-release: 4-8 mg PO 12 hourly Max dose: 32 mg/day
Terbutaline	2.5-5 mg PO 8 hourly
Tulobuterol	1-2 mg PO 12 hourly May increase dose to 2 mg PO 8 hourly
Short-Acting Beta₂-Agonist Bronchodilators (Oral)
Clenbuterol	20-40 mcg PO 12 hourly Max dose: 80 mcg/day	Adverse Reactions CV effects (angina, palpitation, chest pain, tachycardia); CNS effects (headache, irritability, seizure); Dermatologic effects (urticaria, rash); Endocrine effects (hyperglycemia, hypokalemia); Respiratory effects (bronchospasm, cough, viral infection); Other effects (anaphylaxis, allergy) Special Instructions Use with caution in patients with hyperthyroidism, DM, myocardial insufficiency, arrhythmia, hypertension, HF, glaucoma, hypokalemia, seizure disorder Monitor K levels
Fenoterol	Initially 2.5 mg PO 12 hourly, may increase up to 5 mg PO 8 hourly Max dose: 15 mg/day
Hexoprenaline	0.5-1 mg PO 8 hourly
Orciprenaline (Metaproterenol)	20 mg PO 6-8 hourly
Procaterol	50 mcg PO 12-24 hourly Minitab: 25-50 mcg PO 12 hourly
Salbutamol (Albuterol)	2-4 mg PO 6-8 hourly Max dose: 32 mg/day
Terbutaline	2.5-5 mg PO 6-8 hourly Max dose: 15 mg/day
Tretoquinol (Trimetoquinol)	2-4 mg PO 8-12 hourly
Long-Acting Beta₂-Agonist Bronchodilator (Topical)
Tulobuterol	2 mg via transdermal patch 24 hourly	Adverse Reactions Musculoskeletal effects (fine tremors, muscle cramps); CV effects (tachycardia, palpitations, peripheral vasodilatation); CNS effects (headache, nervous tension); Other effect (hypersensitivity reactions) Special Instructions Contraindicated in patients with phaeochromocytoma Use with caution in patients with hyperthyroidism, myocardial insufficiency, arrhythmias, susceptibility to QT-interval prolongation, hypertension, DM To be used with anti-inflammatory therapy
Corticosteroids (Systemic)
Prednisone/Prednisolone	30-40 mg/day PO x 5 days	Adverse Reactions GI effects (gastritis, abdominal pain, diarrhea, dyspepsia, nausea); Endocrine effects (adrenocortical insufficiency, impaired glucose tolerance); Musculoskeletal effects (osteoporosis, muscle wasting, pain or weakness); Other effects (increased susceptibility to infection, impaired wound healing, electrolyte imbalances, weight gain, skin thinning leading to striae and easy bruising, cataracts, glaucoma) Special Instructions Patients on long-term corticosteroids should receive preventive treatment for osteoporosis Contraindicated in patients with fungal infections and those receiving live/attenuated vaccines Use with caution in patients with HF, acute MI, DM, GI diseases, hepatic/renal impairment, myasthenia gravis, osteoporosis, seizure disorder, thyroid disease, Cushing’s syndrome, infection Long-term treatment is not recommended due to its side effects
Methylxanthines (Oral)
Aminophylline	Extended-release: 225-450 mg PO 12 hourly	Adverse Reactions GI effects (irritation, nausea/vomiting, abdominal pain, diarrhea, gastroesophageal reflux); CNS effects (CNS stimulation, headache, anxiety, restlessness, dizziness, tremor); CV effects (palpitations, tachycardia) Serum concentration >15-20 mcg/mL (85-110 µmol/L) are associated with increased risk of adverse effects including lethal adverse reactions Special Instructions Use with caution in elderly patients, with peptic ulcer, hyperthyroidism, hypertension, cardiac arrhythmias or other CV disease, epilepsy, HF, hepatic dysfunction or chronic alcoholism, acute febrile illness Many drug interactions occur with Theophylline including smoking (which increases Theophylline clearance) Serum concentration monitoring is necessary to ensure concentration is within therapeutic range Serum concentration needs to be measured if a patient is changed from one extended-release product to another Optimal therapeutic concentration: 10-20 mcg/mL (55-110 µmol/L)
Choline theophyllinate	Initial dose: 0.2-0.4 mg PO 24 hourly Maintenance dose: 0.8-1.2 g PO divided 6-8 hourly
Diprophylline (Diphylline)	15 mg/kg PO 6 hourly
Doxofylline	400 mg PO 8-12 hourly
Theophylline¹	250 mg PO 12 hourly Extended-release: Initial dose: 5-8 mg/kg/day PO divided 12 hourly Usual dose: 7-12 mg/kg/day divided 12 hourly Max dose: 800 mg/day
Methylxanthines (Parenteral)
Theophylline	0.3 mg/kg/hr continuous IV infusion Adjust dosage based on subsequent serum concentration Usual dose: 400 mg/day	Adverse Reactions GI effects (irritation, nausea/vomiting, abdominal pain, diarrhea, gastroesophageal reflux); CNS effects (CNS stimulation, headache, anxiety, restlessness, dizziness, tremor); CV effects (palpitations, tachycardia) Serum concentration >15-20 mcg/mL (85-110 micromol/L) are associated with increased risk of adverse effects including lethal adverse reactions Special Instructions Administer IV injection very slowly to prevent dangerous CNS and CV side effects Use with caution in elderly patients, with peptic ulcer, hyperthyroidism, hypertension, cardiac arrhythmias or other CV disease, epilepsy, HF, hepatic dysfunction or chronic alcoholism, acute febrile illness Many drug interactions occur with Theophylline including smoking (which increases Theophylline clearance) Serum concentration monitoring is necessary to ensure concentration is within therapeutic range Optimal therapeutic concentration: 10-20 mcg/mL (55-110 µmol/L)
Monoclonal Antibodies
Dupilumab	300 mg SC every other week	Adverse Reactions GI effects (diarrhea, gastritis); Respiratory effects (rhinitis, nasopharyngitis); Other effects (viral infection, conjuctivitis, headache, backpain, arthralgia, UTI, injection site reactions, eosinophilia, toothache) Special Instructions Should not be used for acute asthma symptoms or exacerbations, acute bronchospasm, or status asthmaticus Avoid use of live vaccines during treatment; consider completing age-appropriate vaccinations prior to start of treatment Avoid abrupt discontinuation of systemic, topical or inhaled corticosteroids Use with caution in patients with conjunctivitis, keratitis, comorbid asthma, parasitic infections, vasculitic rash, worsened pulmonary symptoms, cardiac symptoms and/or neuropathy presenting with eosinophilia
Phosphodiesterase-4 Inhibitor
Roflumilast	500 mcg PO 24 hourly	Adverse Reactions GI effects (diarrhea, nausea, abdominal pain); Other effects (decrease weight and appetite, insomnia, headache) Special Instructions Contraindicated in patients with moderate to severe liver impairment Use with caution in patients with severe immunological diseases, severe acute infectious diseases, cancers (except basal cell carcinoma), CHF, immunosuppressant therapy, galactose intolerance, Lapp lactase deficiency and glucose-galactose malabsorption Body weight should be monitored

¹Many different formulations for Theophylline are available. Please see the latest MIMS for specific formulations and prescribing information.

COPD Preparations (Combination Products)

Drug	Dosage	Remarks
Aclidinium/Formoterol	340 mcg/12 mcg: 1 inhalation 12 hourly 400 mcg/12 mcg:1 inhalation 12 hourly	Adverse Reactions Aclidinium Respiratory effects (upper respiratory tract infection [URTI], bronchitis, sinusitis, pharyngitis); CV effects (chest pain, palpitation); CNS effects (headache, dizziness); GI effects (dry mouth, bad taste, dyspepsia, nausea, constipation, diarrhea); Hypersensitivity effects (urticaria, angioedema, rash, bronchospasm) Beclometasone and Budesonide Local effects (cough from upper airway irritation, dysphonia, oropharyngeal candidiasis); Paradoxical bronchospasm Risk of systemic effects will depend on dose, potency of the corticosteroid, absorption from the gut, delivery system, the use of spacers and the drug’s pharmacokinetics Long-term use of high-dose steroids may result in cataracts, glaucoma, skin thinning, easy bruising and adrenal suppression Formoterol CV effects (angina, palpitation, chest pain, tachycardia); CNS effects (headache, irritability, seizure); Dermatologic effects (urticaria, rash); Endocrine effects (hyperglycemia, hypokalemia); Respiratory effects (dyspnea, bronchospasm,cough, viral infection); Other effects (anaphylaxis, allergy, pain, diarrhea) Salbutamol CV effects (angina, palpitation, chest pain, tachycardia); CNS effects (headache, irritability, seizure); Dermatologic effects (urticaria, rash); Endocrine effects (hyperglycemia, hypokalemia); Respiratory effects (bronchospasm, cough, viral infection); Other effects (anaphylaxis, allergy) Special Instructions Aclidinium Avoid contact of inhalation solution with eyes Use with caution in patients with prostatic hyperplasia, unstable ischemic heart disease, severe renal impairment, patients predisposed to narrow-angle glaucoma, bladder neck obstruction, urinary retention Check patient’s inhaler technique for optimum delivery of drug Beclometasone and Budesonide Local effects may be minimized by using a spacer, gargling and spitting out with water Not for relief of acute bronchospasm Contraindicated in patients with recent nasal septal ulcers, surgery, or trauma Use with caution in patients with HF, acute MI, DM, GI diseases, hepatic/renal impairment, myasthenia gravis, osteoporosis, seizure disorder, thyroid disease Formoterol Use with caution in patients with hyperthyroidism, DM, MI, HF, arrhythmia, hypertension, glaucoma, hypokalemia, seizure disorder Monitor K levels Check patient’s inhaler technique for optimum delivery of drug Salbutamol Use with caution in patients with hyperthyroidism, DM, myocardial insufficiency, arrhythmia, hypertension, HF, glaucoma, hypokalemia, seizure disorder Monitor K levels Check patient’s inhaler technique for optimum delivery of drug Beclometasone/Salbutamol Use not to exceed 10 days
Beclometasone/Formoterol	100 mcg/6 mcg: 2 inhalations 12 hourly
Beclometasone/Salbutamol	50 mcg/100 mcg: 2 puffs 4-6 hourly Max dose: 12 puffs/day
Budesonide/Formoterol	80 mcg/2.25 mcg: 4 inhalations 12 hourly 160 mcg/4.5 mcg: 2 inhalations 12 hourly 200 mcg/6 mcg: 2 inhalations 12 hourly 320 mcg/9 mcg: 1 inhalation 12 hourly 400 mcg/12 mcg: 1-2 inhalations 12 hourly
Fluticasone/Vilanterol	100 mcg/25 mcg: 1 inhalation 24 hourly	Adverse Reactions Respiratory effects (nasopharyngitis, pneumonia, cough, pharyngitis, URTI, oropharyngeal pain, sinusitis, rhinitis); GI effect (abdominal pain); Other effects (headache, pyrexia, back pain, muscle spasms) Special Instructions Discontinue use if paradoxical bronchospasm occurs Avoid in patients with severe milk-protein allergy Use with caution in patients with CV disorders, visual disturbances, hypokalemia, pulmonary TB
Glycopyrronium/Formoterol	9 mcg/4.8 mcg: 2 inhalations 12 hourly	Adverse Reactions Formoterol and Indacaterol CV effects (angina, palpitation, chest pain, tachycardia); CNS effects (headache, irritability, seizure); Dermatologic effects (urticaria, rash); Endocrine effects (hyperglycemia, hypokalemia); Respiratory effects (dyspnea, bronchospasm, cough, viral infection); Other effects (anaphylaxis, allergy, pain, diarrhea) Fenoterol and Salbutamol CV effects (angina, palpitation, chest pain, tachycardia); CNS effects (headache, irritability, seizure); Dermatologic effects (urticaria, rash); Endocrine effects (hyperglycemia, hypokalemia); Respiratory effects (bronchospasm, cough, viral infection); Other effects (anaphylaxis, allergy) Glycopyrronium bromide and Ipratropium bromide Respiratory effects (upper respiratory tract infection [URTI], bronchitis, sinusitis, pharyngitis); CV effects (chest pain, palpitation); CNS effects (headache, dizziness); GI effects (dry mouth, bad taste, dyspepsia, nausea, constipation, diarrhea); Hypersensitivity effects (urticaria, angioedema, rash, bronchospasm) Special Instructions Formoterol and Indacaterol Use with caution in patients with hyperthyroidism, DM, MI, HF, arrhythmia, hypertension, glaucoma, hypokalemia, seizure disorder Monitor K levels Check patient’s inhaler technique for optimum delivery of drug Fenoterol and Salbutamol Use with caution in patients with hyperthyroidism, DM, myocardial insufficiency, arrhythmia, hypertension, HF, glaucoma, hypokalemia, seizure disorder Monitor K levels Check patient’s inhaler technique for optimum delivery of drug Glycopyrronium bromide and Ipratropium bromide Avoid contact of inhalation solution with eyes Use with caution in patients with prostatic hyperplasia, unstable ischemic heart disease, severe renal impairment, patients predisposed to narrow-angle glaucoma, bladder neck obstruction, urinary retention Check patient’s inhaler technique for optimum delivery of drug Glycopyrronium: Not for initial treatment of bronchospasm
Indacaterol/Glycopyrronium	110 mcg/50 mcg inhalation cap: 1 inhalation 24 hourly at the same time each day
Ipratropium/Fenoterol	20 mcg/50 mcg: 1-2 puffs 8 hourly Max dose: 8 puffs/24 hourly 0.5 mg/1.25 mg/4 mL inhalation solution UDV: 1 nebulization 24 hourly 0.25 mg/0.5 mg solution: 1-2.5 mL (20-50 drops) 24 hourly Severe cases: 4 mL (80 drops) 24 hourly
Ipratropium bromide/Salbutamol	20 mcg/100 mcg: 1-2 inhalations 6-8 hourly Max dose: 12 inhalations/day 500 mcg/2.5 mg/2.5 mL inhalation solution UDV: 2.5 mL 6-8 hourly
Salmeterol/Fluticasone	25 mcg/125 mcg: 2 inhalations 12 hourly 25 mcg/250 mcg: 2 inhalations 12 hourly 50 mcg/250 mcg: 1 inhalation 12 hourly 50 mcg/500 mcg: 1 inhalation 12 hourly	Adverse Reactions Fluticasone Local effects (cough from upper airway irritation, dysphonia, oropharyngeal candidiasis); Paradoxical bronchospasm Risk of systemic effects will depend on dose, potency of the corticosteroid, absorption from the gut, delivery system, the use of spacers and the drug’s pharmacokinetics Long-term use of high-dose steroids may result in cataracts, glaucoma, skin thinning, easy bruising and adrenal suppression Salmeterol CV effects (angina, palpitation, chest pain, tachycardia); CNS effects (headache, irritability, seizure); Dermatologic effects (urticaria, rash); Endocrine effects (hyperglycemia, hypokalemia); Respiratory effects (dyspnea, bronchospasm, cough, viral infection); Other effects (anaphylaxis, allergy, pain, diarrhea) Special Instructions Fluticasone Local effects may be minimized by using a spacer, gargling and spitting out with water Not for relief of acute bronchospasm Contraindicated in patients with recent nasal septal ulcers, surgery, or trauma Use with caution in patients with HF, acute MI, DM, GI diseases, hepatic/renal impairment, myasthenia gravis, osteoporosis, seizure disorder, thyroid disease Salmeterol Use with caution in patients with hyperthyroidism, DM, myocardial infarction (MI), HF, arrhythmia, hypertension, glaucoma, hypokalemia, seizure disorder Monitor K levels Check patient’s inhaler technique for optimum delivery of drug
Tiotropium/Olodaterol	2.5 mcg/2.5 mcg: 2 puffs 24 hourly at the same time each day	Adverse Reactions Olodaterol CV effects (angina, palpitation, chest pain, tachycardia); CNS effects (headache, irritability, seizure); Dermatologic effects (urticaria, rash); Endocrine effects (hyperglycemia, hypokalemia); Respiratory effects (dyspnea, bronchospasm, cough, viral infection); Other effects (anaphylaxis, allergy, pain, diarrhea) Tiotropium Respiratory effects (URTI, bronchitis, sinusitis, pharyngitis); CV effects (chest pain, palpitation); CNS effects (headache, dizziness); GI effects (dry mouth, bad taste, dyspepsia, nausea, constipation, diarrhea); Hypersensitivity effects (urticaria, angioedema, rash, bronchospasm) Special Instructions Olodaterol Use with caution in patients with hyperthyroidism, DM, MI, HF, arrhythmia, hypertension, glaucoma, hypokalemia, seizure disorder Monitor K levels Check patient’s inhaler technique for optimum delivery of drug Tiotropium Avoid contact of inhalation solution with eyes Use with caution in patients with prostatic hyperplasia, unstable ischemic heart disease, severe renal impairment, patients predisposed to narrow-angle glaucoma, bladder neck obstruction, urinary retention Check patient’s inhaler technique for optimum delivery of drug Not for initial treatment of bronchospasm
Umeclidinium/ Vilanterol	62.5 mcg/25 mcg: 1 inhalation 24 hourly at the same time each day	Adverse Reactions Respiratory effects (cough, sinusitis, nasopharyngitis, pharyngitis, URTI, oropharyngeal pain); GUT effect (urinary tract infection [UTI]); GI effect (constipation); Other effects (headache, dry mouth) Special Instructions Discontinue use if paradoxical bronchospasm occurs Avoid in patients with severe milk-protein allergy Use with caution in patients with glaucoma, DM, CV disorders, prostatic hypertrophy, bladder neck obstruction, hypokalemia
Beclometasone/Formoterol/Glycopyrronium	100 mcg/6 mcg/10 mcg (12.5 mcg Glycopyrronium Br): 2 inhalations 12 hourly Max dose: 4 inhalations/day	Adverse Reactions Beclometasone Local effects (cough from upper airway irritation, dysphonia, oropharyngeal candidiasis); Paradoxical bronchospasm Risk of systemic effects will depend on dose, potency of the corticosteroid, absorption from the gut, delivery system, the use of spacers and the drug’s pharmacokinetics Long-term use of high-dose steroids may result in cataracts, glaucoma, skin thinning, easy bruising and adrenal suppression Formoterol CV effects (angina, palpitation, chest pain, tachycardia); CNS effects (headache, irritability, seizure); Dermatologic effects (urticaria, rash); Endocrine effects (hyperglycemia, hypokalemia); Respiratory effects (dyspnea, bronchospasm,cough, viral infection); Other effects (anaphylaxis, allergy, pain, diarrhea) Glycopyrronium Respiratory effects (URTI, bronchitis, sinusitis, pharyngitis); CV effects (chest pain, palpitation); CNS effects (headache, dizziness); GI effects (dry mouth, bad taste, dyspepsia, nausea, constipation, diarrhea); Hypersensitivity effects (urticaria, angioedema, rash, bronchospasm) Special Instructions Beclometasone Local effects may be minimized by using a spacer, gargling and spitting out with water Not for relief of acute bronchospasm Contraindicated in patients with recent nasal septal ulcers, surgery, or trauma Use with caution in patients with HF, acute MI, DM, GI diseases, hepatic/renal impairment, myasthenia gravis, osteoporosis, seizure disorder, thyroid disease Formoterol Use with caution in patients with hyperthyroidism, DM, MI, HF, arrhythmia, hypertension, glaucoma, hypokalemia, seizure disorder Monitor K levels Check patient’s inhaler technique for optimum delivery of drug Glycopyrronium Avoid contact of inhalation solution with eyes Use with caution in patients with prostatic hyperplasia, unstable ischemic heart disease, severe renal impairment, patients predisposed to narrow-angle glaucoma, bladder neck obstruction, urinary retention Check patient’s inhaler technique for optimum delivery of drug Not for initial treatment of bronchospasm
Budesonide/Glycopyrronium/Formoterol fumarate	160 mcg/7.2 mcg (9 mcg Glycopyrronium Br)/4.8 mcg (5 mcg Formoterol fumarate dihydrate) 2 inhalations 12 hourly Max dose: 4 inhalations/day	Adverse Reactions Respiratory effects (pneumonia, dysphonia, cough);GI effects (oral candidiasis, nausea); CNS effects (insomnia, anxiety, headache); Other effects (hyperglycemia, UTI, muscle spasms) Special Instructions Not for initial treatment of acute bronchospasm or acute COPD exacerbation (ie as rescue therapy) Use with caution in patients with thyrotoxicosis, severe CV disorder (eg ischemic heart disease, tachyarrythmias, severe HF, prolonged QTc-interval), symptomatic prostatic hyperplasia, urinary retention or narrow-angle glaucoma, severe renal and hepatic impairment Cushing's syndrome, cushingoid features, adrenal suppression, decreased bone mineral density, cataract and glaucoma may occur in high doses for long periods
Fluticasonefuroate/Umeclidinium/Vilanterol	100 mcg/62.5 mcg/25 mcg: 1 inhalation 24 hourly at the same time each day	Adverse Reactions Respiratory effects (pneumonia, URTI, bronchitis, influenza, sinusitis, pharyngitis, rhinitis, cough, dysphonia); GI effects (dysgeusia, constipation, diarrhea, gastroenteritis, oral candidiasis, oropharyngeal pain); Other effects (headache, back pain, arthralgia) Special Instructions Not for initial treatment of acute bronchospasm Avoid in patients with severe milk-protein allergy Use with caution in patients with moderate to severe hepatic impairment, severe CV disease, pulmonary tuberculosis, chronic or untreated infections, ocular herpes simplex, narrow-angle glaucoma, prostatic hyperplasia, bladder-neck obstruction, DM, convulsive disorders, thyrotoxicosis, ketoacidosis, Lapp lactase deficiency or glucose-galactose malabsorption, on corticosteroids or long-acting beta₂-agonist monotherapy Hypercortisolism, adrenal suppression and adrenal function impairment may occur

Cough & Cold Preparations

Drug	Dosage	Remarks
Acetylcysteine (N-acetylcysteine)	200 mg PO 8-12 hourly or 300 mg PO 12 hourly or 600 mg PO 12-24 hourly or 3x/week or 3-5 mL of 20% solution or 6-10 mL of 10% solution via nebulization 6-8 hourly	Adverse Reactions GI effects (GI disturbances, nausea/vomiting); Hypersensitivity reactions (bronchospasm, rashes); Other effect (hypotension) Acetylcysteine inhalation: Rhinitis, stomatitis Special Instructions Acetylcysteine effervescent tab/granules for oral solution: Avoid in patients with phenylketonuria Use with caution in patients with gastric or duodenal ulcer Ambroxol: Use with caution in patients with galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption
Ambroxol	30-120 mg PO divided 8-12 hourly or 30 mg PO 8 hourly or 60 mg PO 12 hourly Extended-release: 75 mg PO 24 hourly
Bromhexine	8 mg PO 8 hourly
Carbocisteine (Carbocysteine)	Initial dose: 750 mg PO 8 hourly, then 375 mg PO 6-12 hourly or 750 mg PO 8-12 hourly or 500 mg PO 8 hourly or 2.7 g dissolved in ½ glass of water PO 24 hourly
Erdosteine	300 mg PO 8-12 hourly	Adverse Reactions GI disturbances (GI discomfort, rarely taste alterations, nausea/vomiting, diarrhea); Other effects (rarely, headache, dyspnea, urticaria, erythema, dermatitis) Special Instructions Contraindicated in patients with active peptic ulcer, hepatic cirrhosis, hepatic impairment, cystathionine-synthetase enzyme deficiency and severe renal failure
Guaifenesin	600-1,200 mg PO 12 hourly or 200-400 mg PO 4 hourly or 100-200 mg PO 6-8 hourly Max dose: 2,400 mg/day	Adverse Reactions GI disturbances (GI discomfort, nausea/vomiting) Special Instructions Use with caution in patients with persistent or chronic cough, asthma, chronic bronchitis or emphysema Discontinue use if cough persists for >7 days with fever, rash or persistent headache

Macrolide

Drug

Dosage

Remarks

Azithromycin

For acute bacterial exacerbations:
500 mg PO 24 hourly for 3 days or
500 mg PO on day 1, then 250 mg PO 24 hourly for days 2-5

Adverse Reactions

GI effects (nausea/vomiting, abdominal discomfort, diarrhea and other GI disturbances, antibiotic-associated diarrhea/colitis); Other effect (candidal infections)
Dose-related tinnitus/hearing loss has occurred with some macrolides

Special Instructions

May take with food to decrease gastric distress
Physician should be informed if the patient vomits within 5-60 minutes after taking the dose
Use with caution in patients with hepatic dysfunction, severe renal impairment or cardiac dysfunction (especially with long QTc interval)

Disclaimer

All dosage recommendations are for non-elderly adults with normal renal and hepatic function unless otherwise stated.
Not all products are available or approved for above use in all countries.
Products listed in the Drug Summary are based on indications stated in the locally approved product monographs.
Please refer to local product monographs in Related MIMS Drugs for country-specific prescribing information.

Chronic Obstructive Pulmonary Disease Drug Summary