Cough suppressants or anti-tussive therapy should not be used in stable COPD.[4,15]

Mucolytic treatment, such as with carbocisteine (which influences the nature and amount of mucus glycoprotein secreted by the respiratory tract), is an option for a chronic cough with sputum production, but should only be continued if symptoms improve. Mucolytics should not be used prophylactically to prevent COPD exacerbations.[4,18]

Due to the need to monitor blood levels, theophylline (in a modified release format) should be reserved for use after a trial of short-acting and long-acting bronchodilators, or for people who cannot use inhaled therapy. Additional care should be taken with older patients.[4]

Roflumilast, an oral phosphodiesterase-4 (PDE4) inhibitor, is indicated for severe COPD associated with chronic bronchitis as an add-on to bronchodilator treatment. Inhibiting PDE4 increases intracellular levels of cyclic adenosine monophosphate (cAMP) helping counteract inflammatory pathway malfunctions in airway tissues and can reduce sputum neutrophil levels in COPD.[18]

It should be restricted to use in people who have had two or more exacerbations in the previous 12 months despite triple inhaled therapy with a LAMA + LABA + ICS.[4]

Prophylactic antibiotic use (such as azithromycin 250mg threes time a week) is another consideration but the extent and nature of possible existing infection or other lung condition such as bronchiectasis needs proper investigation. The decision should also consider factors such as the response to inhaled therapy and how well the patient can optimise sputum clearance.

For COPD exacerbations, a patient’s care plan may recommend keeping a short course of antibiotics (non-macrolide if they are taking prophylactic azithromycin) and oral corticosteroids at home.[15]