From the Guidelines
According to the GOLD criteria for COPD, long-acting bronchodilators, specifically long-acting muscarinic antagonists (LAMAs), are the first-line maintenance medications for COPD treatment. The most recent and highest quality study, published in 2023 1, recommends LABD maintenance therapy in all symptomatic patients with COPD confirmed by spirometry. LAMAs, such as tiotropium, umeclidium, glycopyrronium, or aclidinium, are preferred over long-acting beta-2 agonists (LABAs) like salmeterol, formoterol, indacaterol, or olodaterol, due to their better reduction in exacerbation rates compared to LABAs 1.
Key Points to Consider
- Long-acting muscarinic antagonists (LAMAs) are the preferred initial maintenance therapy for COPD treatment
- Combination therapy with both LAMA and LABA may be appropriate for patients with more severe symptoms or high risk of exacerbations
- Inhaled corticosteroids are not recommended as first-line monotherapy but may be added for patients with a history of exacerbations despite appropriate bronchodilator treatment
- The choice of inhaler device should be based on the patient's ability to use the device correctly, as proper inhaler technique is crucial for medication effectiveness
Medication Options
- LAMAs: tiotropium, umeclidium, glycopyrronium, or aclidinium
- LABAs: salmeterol, formoterol, indacaterol, or olodaterol
- Combination therapy: LAMA and LABA
Important Considerations
- Patient's ability to use the inhaler device correctly
- History of exacerbations despite appropriate bronchodilator treatment
- Elevated eosinophil counts
The 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1 supports the use of LAMAs as first-line maintenance therapy, and the 2017 GOLD executive summary 1 provides evidence for the effectiveness of LAMAs in reducing exacerbation rates and improving symptoms. Therefore, LAMAs should be considered the first-line maintenance medication for COPD treatment, with combination therapy with LABA considered for patients with more severe symptoms or high risk of exacerbations.
From the Research
First Line Maintenance Medication for COPD
According to the gold criteria for COPD, the first line maintenance medication includes:
- Long-acting muscarinic receptor antagonists (LAMA)
- Long-acting β2-adrenoreceptor agonists (LABA)
- LAMA/LABA fixed dose combinations (FDCs) 2, 3, 4, 5
Types of LAMA and LABA
Some of the approved LAMA include:
- Tiotropium bromide
- Glycopyrronium bromide
- Umeclidinium bromide
- Aclidinium bromide 2 Some of the approved LABA include:
- Indacaterol
- Salmeterol
- Formoterol 2
LAMA/LABA Fixed Dose Combinations
LAMA/LABA FDCs provide the convenience of two bronchodilators with different mechanisms of action in a single inhaler. Some examples of approved or pending approval LAMA/LABA FDCs include:
- Indacaterol/glycopyrronium
- Umeclidinium/vilanterol
- Olodaterol/tiotropium 2 Aclidinium/formoterol is also a LAMA/LABA dual bronchodilator used as a maintenance treatment for patients with COPD 3
Evidence for LAMA/LABA Combinations
Most studies show that LAMA/LABA treatment leads to greater improvements in lung function and symptoms than LAMA monotherapy or ICS/LABA treatment 5 LAMA/LABA combinations are recommended as an initial maintenance therapy option for symptomatic patients with low exacerbation risk and severe breathlessness or patients with severe symptoms who are at risk of exacerbations 5