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

Treatment Recommendations for Chronic Obstructive Pulmonary Disease (COPD)

For COPD patients, the recommended first-line treatment is long-acting bronchodilators, with LABA/LAMA combinations preferred for patients with persistent symptoms or those at high risk for exacerbations. 1, 2

Treatment Algorithm Based on COPD Severity

Initial Treatment by Patient Group

1. Mild COPD (Few symptoms)

   • Short-acting bronchodilators as needed
   • Smoking cessation (essential at all stages)

2. Moderate COPD (Persistent symptoms)

   • Long-acting bronchodilator monotherapy (LAMA or LABA)
   • If breathlessness persists on monotherapy, use LABA/LAMA combination

3. Severe COPD (High exacerbation risk)

   • LABA/LAMA combination is preferred first-line therapy
   • LAMA monotherapy is preferred over LABA if single agent is chosen
   • Consider LABA/ICS for patients with:
     • History suggestive of asthma-COPD overlap
     • Blood eosinophil count ≥300 cells/μL

Escalation Therapy for Persistent Exacerbations

If exacerbations persist despite initial therapy:

1. On LABA/LAMA therapy:

   • Escalate to LABA/LAMA/ICS triple therapy, OR
   • Switch to LABA/ICS (if eosinophil count is high)

2. On LABA/LAMA/ICS with continued exacerbations:

   • Add roflumilast for patients with:
     • FEV1 <50% predicted
     • Chronic bronchitis
     • History of hospitalization for exacerbation 1, 2
   • Add macrolide (in former smokers)
   • Consider stopping ICS if pneumonia risk is high

Important Cautions and Considerations

• ICS therapy: Long-term monotherapy with ICS is not recommended (Evidence A) 1
• Roflumilast: Not recommended for patients with moderate to severe liver impairment (Child-Pugh B or C) 3
• Oral corticosteroids: Long-term therapy is not recommended (Evidence A) 1
• Statin therapy: Not recommended for prevention of exacerbations (Evidence A) 1

Non-Pharmacological Management

• Pulmonary rehabilitation: Recommended for symptomatic patients, especially with FEV1 <50% predicted 2
• Oxygen therapy: Long-term oxygen therapy prolongs life in hypoxemic patients (PaO₂ <7.3 kPa) and should be administered for at least 15 hours/day 2
• Vaccinations: Annual influenza vaccination and pneumococcal vaccination are recommended 2

Management of Acute Exacerbations

• Increase dose/frequency of short-acting bronchodilators 2
• Consider systemic corticosteroids for severe exacerbations 2
• Prescribe antibiotics if two or more of the following are present:
  • Increased breathlessness
  • Increased sputum volume
  • Development of purulent sputum 2

Monitoring and Follow-up

• Regular assessment of symptoms, exacerbation frequency, and spirometry
• Reassessment of inhaler technique at each visit
• Follow-up within 4-6 weeks after exacerbation 2

The treatment approach for COPD must be tailored based on symptom severity, exacerbation risk, and individual patient factors. Long-acting bronchodilators remain the cornerstone of therapy, with combination therapies reserved for those with persistent symptoms or exacerbations despite initial treatment.