Strategy for Early Treatment of Exacerbations in COPD: Standing Prescriptions of Advair With a Written Action Plan in the Event of an Exacerbation

The purpose of this pilot study is to determine whether early treatment of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) with a combination therapy, Salmeterol + Fluticasone Propionate (SFP - Advair) will reduce the use of prednisone, known as the conventional treatment.

Primary objective: To determine whether early treatment with combination therapy (SFP) can reduce the use of prednisone (the conventional treatment) in the event of an AECOPD.

Secondary objectives:

* To evaluate the feasibility of this treatment approach and to provide pilot data (needed for a larger multi-centre clinical trial;
* To evaluate the feasibility and need of assessment during and after exacerbation onset, health-related quality of life and physical activity;
* To evaluate the safety of this approach; this is in terms of the delay in starting prednisone and an unfavourable outcome (ER visits and/or hospitalization).

BACKGROUND Acute exacerbations of COPD (AECOPD) are of major importance since they are associated with adverse effects on morbidity, health status, and costs. Conventional treatment includes the use of antibiotics and oral corticosteroids (OCS). However, OCS is associated with significant side effects. This is of considerable importance since exacerbation occurs on average 2 to 4 times per year in COPD patients. Alternative treatment such as high dose inhaled corticosteroids has also been shown to be effective in the treatment of AECOPD. Recently, studies have clearly demonstrated the effect of combination therapy (SFP) on key inflammatory cells and a marked enhance anti-inflammatory effect when compared to inhaled corticosteroids alone. Inhaled corticosteroids have a high level of topical anti-inflammatory activity and a low level of systemic. Additionally, combination therapy with inhaled corticosteroids and long-acting β2-adrenoceptor agonists (SFP) appears to produce significant anti-inflammatory effects in COPD airways that are not seen when inhaled or oral steroids are used alone. This could offer a potential for an alternative treatment to oral corticosteroids in AECOPD.

RATIONALE None of the inhaled treatments is likely to be adopted and to replace the use of OCS for the treatment of AECOPD unless it is used promptly at the onset of symptom worsening. Early treatment has been shown to have clinical importance in accelerating symptom recovery and reducing hospital admission. Recently, the investigators have demonstrated that the early treatment of AECOPD can be achieved by the implementation of a written action plan as part of a self-management education.

The use of action plans helps COPD patients recognize symptom changes, implement self-care and self-initiate a customized prescription (antibiotics \& oral steroids) in the event of an exacerbation. Self-management education programs with a written action plan that includes standing prescriptions with combination therapy (SFP) in the event of an exacerbation may be promising in reducing the use of prednisone in AECOPD, the conventional treatment.

Eligibility Criteria:
Inclusion Criteria:

* Diagnosis of stable COPD;
* 40 years or older;
* Smoking history of at least 10 pack-years;
* Forced Expiratory Volume in one second (FEV1) ≤ 70 % of predicted value and FEV1 / Forced Vital Capacity (FVC) \< 0.70;
* Dyspnea ≥ 2 on the Medical Research Council (MRC) scale;
* At least 2 exacerbations requiring prednisone treatment in the past 3 years;
* Using a written action plan and having demonstrated adequate use of the self-administered antibiotic \& prednisone (adequate use defined as prednisone started by the patient within 72 hours of symptom worsening and patient called the case-manager as recommended for following the response);
* Already on Advair BID (twice a day) as a maintenance therapy or able to switch over to Advair if already taking another combination medication (Symbicort) as maintenance therapy for COPD.

Exclusion Criteria:

* History of asthma or allergic rhinitis before the age of 40;
* Regular use of oxygen, oral corticosteroids, antibiotics;
* Unstable or life threatening co-morbid condition;
* Medical conditions or taking medications known to affect tremor and/or heart rate (HR).
* Pre-existing medical conditions or on concomitant medications contraindicated with salmeterol or fluticasone propionate (e.g. monoamine oxidase inhibitors and tricyclic antidepressants, beta-adrenergic receptor blocking agents, non potassium-sparing diuretics, inhibitors of cytochrome P450 (ritonavir, ketoconazole));
* On theophyllines.
* Colonized with pseudomonas aeruginosa.