What is the first line treatment for Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

The first-line treatment for COPD should be a long-acting bronchodilator, with a combination of a long-acting beta-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) recommended for patients with moderate to severe symptoms or frequent exacerbations, as supported by the most recent guideline from 2023 1. This approach is based on the latest evidence, which suggests that LABA/LAMA combination therapy improves symptoms, reduces exacerbations, and may even reduce mortality in patients with COPD. The 2023 Canadian Thoracic Society guideline recommends LABA/LAMA combination therapy as the first-line treatment for patients with moderate to severe COPD, with a step up to single-inhaler triple therapy (LABA/LAMA/ICS) for those with persistent symptoms despite dual therapy 1. Some key points to consider when initiating treatment for COPD include:

• The use of short-acting bronchodilators, such as short-acting beta-agonists (SABAs) or short-acting muscarinic antagonists (SAMAs), for mild, intermittent symptoms 1
• The preference for long-acting bronchodilators, including LABAs and LAMAs, for persistent symptoms 1
• The addition of inhaled corticosteroids (ICS) for patients with frequent exacerbations despite optimal bronchodilator therapy or those with asthma-COPD overlap 1
• The importance of comprehensive COPD management, including smoking cessation, pulmonary rehabilitation, vaccinations, and oxygen therapy (if hypoxemic) 1 It's worth noting that the evidence from 2017 suggests that triple inhaled therapy (LABA/LAMA/ICS) may improve lung function, symptoms, and health status, and reduce exacerbations, but the most recent guideline from 2023 recommends a more personalized approach, with a focus on symptom control and exacerbation prevention 1.

From the FDA Drug Label

1. 2 Maintenance Treatment of Chronic Obstructive Pulmonary Disease Wixela Inhub® 250/50 is indicated for the twice-daily maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema.

The first line treatment for COPD is Wixela Inhub® 250/50, which is indicated for the twice-daily maintenance treatment of airflow obstruction in patients with COPD.

• The recommended dosage for patients with COPD is 1 inhalation of Wixela Inhub® 250/50 twice daily, approximately 12 hours apart 2.
• Wixela Inhub® 250/50 is also indicated to reduce exacerbations of COPD in patients with a history of exacerbations.

From the Research

First-Line Treatment for COPD

• The Global Initiative for Chronic Obstructive Lung Disease 2022 report recommends initial pharmacological treatment with a long-acting muscarinic antagonist (LAMA) or a long-acting β2-agonist (LABA) as monotherapy for most patients, or dual bronchodilator therapy (LABA/LAMA) in patients with more severe symptoms, regardless of exacerbation history 3.
• The American Thoracic Society treatment guidelines strongly recommend LABA/LAMA combination therapy over LAMA or LABA monotherapy in patients with COPD and dyspnea or exercise intolerance 3.

LABA/LAMA Combination Therapy

• The combination of LAMA and LABA is thought to leverage different pathways to induce bronchodilation using submaximal drug doses, increasing the benefits and minimizing receptor-specific side effects 4.
• LABA/LAMA combination therapy has been shown to improve pulmonary function, dyspnea, and health-related quality of life, and in some cases, reduce exacerbations 4, 5.
• A systematic review found that LAMA+LABA therapy probably holds similar benefits to LABA+ICS for exacerbations and quality of life, but offers a larger improvement in FEV1 and a slightly lower risk of pneumonia 5.

Comparison with LABA/ICS

• A retrospective observational study found that the LABA/LAMA combination had similar effectiveness to LABA/ICS as measured by exacerbation rates in COPD patients 6.
• Another study found that the odds of having an exacerbation were similar for LAMA+LABA compared with LABA+ICS, and that LAMA+LABA decreased the odds of pneumonia compared with LABA+ICS 5.