The most appropriate treatment is roflumilast. Roflumilast is a phosphodiesterase-4 (PDE-4) inhibitor that is used as add-on therapy to reduce exacerbations in patients with severe COPD associated with chronic bronchitis and a history of recurrent exacerbations despite other therapies. Inhibition of PDE-4 decreases inflammation, which may be helpful in a limited number of patients with COPD in whom inflammation is a significant factor. Roflumilast has minimal bronchodilator activity; however, small improvements in FEV1 are seen in patients also treated with a long-acting anticholinergic agent or a long-acting β2-agonist. Roflumilast should always be used with at least one long-acting bronchodilator. This patent has severe symptomatic COPD (Global Initiative for Chronic Obstructive Lung Disease category D) with recurrent exacerbations, so roflumilast is indicated, along with other agents.
Some studies of macrolide antibiotics suggest that their use reduces exacerbations in a select group of patients with COPD. Macrolides have been shown to reduce exacerbations and improve lung function in patients with cystic fibrosis. However, there is currently insufficient evidence to routinely recommend daily macrolide therapy for the long-term treatment of COPD. There are concerns that long-term azithromycin therapy may be associated with increasing bacterial resistance, especially in patients who previously had Mycobacterium avium-intracellulare infection, and an increased risk of QT prolongation.
Oral glucocorticoids should be reserved for limited periodic use to treat acute exacerbations in patients with COPD. Long-term oral glucocorticoid therapy has been shown to have limited, if any, benefits in COPD. In addition, long-term glucocorticoid therapy has a high risk for significant side effects, including diabetes mellitus, muscle weakness, osteoporosis, and decrease in functional status.
The anti-inflammatory effects of simvastatin were previously believed to reduce exacerbations in COPD. However, a large randomized prospective study showed that, in patients at risk for exacerbations, simvastatin along with usual treatment did not reduce exacerbations or the time to first exacerbation. In addition, simvastatin was found to have no effect on lung function, quality of life, rate of severe adverse events, or mortality.