What are the recommended treatments and dosages for long-term management of Chronic Obstructive Pulmonary Disease (COPD)?

Long-Term Treatment of COPD: Recommended Medications and Dosages

The long-term management of COPD should follow a stepwise approach based on GOLD classification, with treatment escalation from bronchodilators to combination therapy as symptoms and exacerbation risk increase. 1

Initial Assessment and Classification

• COPD patients should be classified according to symptom burden and exacerbation history to guide treatment decisions 1
• Key assessment tools include:
  • COPD Assessment Test (CAT) score or modified Medical Research Council (mMRC) dyspnea scale for symptom assessment 1
  • Forced expiratory volume in 1 second (FEV1) measurement 1
  • Exacerbation history (frequency and severity) 1

Pharmacological Treatment by GOLD Classification

GOLD Group A (Low Symptoms, Low Risk)

• First-line: Short-acting bronchodilator (SABA or SAMA) as needed 1
  • Examples: Albuterol (SABA) 100-200 μg as needed or Ipratropium (SAMA) 20-40 μg as needed
• Alternative: Long-acting bronchodilator (LABA or LAMA) if persistent symptoms 1

GOLD Group B (High Symptoms, Low Risk)

• First-line: Long-acting bronchodilator (LABA or LAMA) 1
  • LAMA options: Tiotropium 18 μg once daily, Umeclidinium 62.5 μg once daily, Glycopyrronium 50 μg once daily, or Aclidinium 400 μg twice daily 2
  • LABA options: Indacaterol 150-300 μg once daily, Formoterol 12 μg twice daily, Salmeterol 50 μg twice daily, or Olodaterol 5 μg once daily 2
• If persistent symptoms: LAMA + LABA combination 1

GOLD Group C (Low Symptoms, High Risk)

• First-line: LAMA monotherapy 1
• Alternative: LABA + ICS if LAMA not tolerated or contraindicated 1

GOLD Group D (High Symptoms, High Risk)

• First-line: LAMA or LAMA + LABA 1
• Alternative: LABA + ICS if asthma-COPD overlap or blood eosinophilia 1
• If exacerbations persist: Triple therapy (LAMA + LABA + ICS) 1
  • Example: Umeclidinium/Vilanterol/Fluticasone furoate 62.5/25/100 μg once daily 3

Specific Medication Recommendations and Dosages

Long-Acting Muscarinic Antagonists (LAMAs)

• Tiotropium: 18 μg once daily via HandiHaler or 5 μg (2 puffs of 2.5 μg) once daily via Respimat 4, 5
• Umeclidinium: 62.5 μg once daily 2
• Glycopyrronium: 50 μg once daily 2
• Aclidinium: 400 μg twice daily 2

Long-Acting Beta-2 Agonists (LABAs)

• Indacaterol: 150-300 μg once daily 2, 6
• Salmeterol: 50 μg twice daily 6
• Formoterol: 12 μg twice daily 6
• Olodaterol: 5 μg once daily 2

Fixed-Dose Combinations

• LABA/LAMA combinations:

  • Indacaterol/Glycopyrronium: 85/43 μg once daily 3
  • Umeclidinium/Vilanterol: 62.5/25 μg once daily 3
  • Tiotropium/Olodaterol: 5/5 μg once daily 3

• LABA/ICS combinations:

  • Salmeterol/Fluticasone: 50/250-500 μg twice daily 7
  • Formoterol/Budesonide: 12/400 μg twice daily 1
  • Vilanterol/Fluticasone furoate: 25/100 μg once daily 1

Additional Treatments for Specific Phenotypes

• Frequent exacerbators with chronic bronchitis: Consider adding Roflumilast 500 μg once daily if FEV1 <50% predicted 1
• COPD with asthmatic features (ACOS): LABA + ICS is recommended as first-line therapy 1
• Patients with persistent exacerbations despite optimal therapy: Consider macrolide therapy (azithromycin 250-500 mg three times weekly) in former smokers 1

Non-Pharmacological Management

• Pulmonary rehabilitation: Recommended for all symptomatic patients, especially those with exercise limitation 1
• Oxygen therapy: Indicated for patients with resting hypoxemia (PaO2 ≤55 mmHg or SaO2 ≤88%) 1
• Vaccinations: Annual influenza vaccination and pneumococcal vaccination (PCV13 and PPSV23) for all COPD patients 1
• Nutritional support: For malnourished patients 1

Important Clinical Considerations

• Inhaled corticosteroids should not be used as monotherapy in COPD 1
• Patients on ICS have an increased risk of pneumonia, particularly those with severe disease 1
• LAMA monotherapy has been shown to be more effective than SABA or SAMA in preventing exacerbations 1
• Consider comorbidities when selecting treatment; use caution with high-dose beta-agonists in patients with cardiovascular disease 1
• Regular follow-up is essential to assess treatment response, adjust therapy as needed, and monitor for adverse effects 1