Prolonged mucolytic therapy in patients with diagnosed COPD

• Working Party – Rudolf, Bellamy, Burrill, Scullion & Thomas •

• This guideline is intended to complement the NICE COPD guideline’s recommendations on mucolytic therapy and provide further guidance on its use in patients with COPD who have the common symptoms of chronic, troublesome cough and sputum production
• Underdiagnosis of COPD is a problem in the UK. Patients who present with frequent cough and sputum, or frequent ‘respiratory infections’, should be assessed for the presence of underlying COPD (including the use of spirometry), particularly if they have a significant smoking history
• Cough and sputum production can affect the patient’s quality of life
• The primary aims of mucolytic therapy are to improve cough and ease sputum expectoration. Associated benefits, e.g. less breathlessness and less frequent coughing, may also be noticed

Assessment

• Assessment is subjective and should aim to identify those patients in whom cough and sputum are troublesome
• It may be helpful to ask about:
  • colour/consistency and amount of sputum
  • difficulty of expectoration
  • timing and duration of symptoms
  • quality of life issues, e.g. embarrassment
  • willingness to consider drug treatment
  • history and frequency of COPD exacerbations
• Management with mucolytic therapy can be considered for adult patients who:
  • have a confirmed diagnosis of COPD
  • have cough and sputum on most days for 3 months, in 2 consecutive years
  • are in a chronic, stable but symptomatic state
• Mucolytic therapy is not suitable if patients:
  • have COPD but do not have long-standing, troublesome cough and sputum
  • have copious, watery sputum
• Consider differential diagnoses:
  • lung cancer
  • bronchiectasis
  • rhinitis or post-nasal drip

Managing cough and sputum

• Symptoms should be managed according to their duration:
  • year-round symptoms may require year-round treatment
  • seasonal symptoms normally require treatment only for the duration of the symptomatic period

Initial trial of therapy

• Trial carbocisteine/mecysteine therapy for 4–6 weeks, at the recommended initial fixed dose
• Discuss points to consider during the trial period with the patient:
  • quantity and colour of sputum
  • ease of expectoration
  • amount of coughing

Review at 4–6 weeks

• Review criteria are subjective, based on the patient’s perception of how their cough and sputum have changed
• It may be helpful to ask the following:
  • is your sputum easier to cough up?
  • has the amount or colour changed?
  • is your cough less bothersome?
  • have you noticed improvement in any other COPD-related symptom?
  • have you noticed any new problems that might be related to the drug?
  • are you happy to continue with therapy?

Continuing therapy

• Continue therapy if:
  • patient reports improvement in cough and sputum production/expectoration
  • no unacceptable side-effects
  • patient perceives benefit in mucolytic therapy
• Therapy for seasonal symptoms:
  • repeat annually, if still of benefit and acceptable to the patient
• Therapy for year-round symptoms
  • less well supported by evidence, but reasonable to continue treatment on long-term basis
  • reduce dose to minimum required for effective symptom control
  • assess continuing benefits of therapy annually