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

Treatment Plan for Chronic Obstructive Pulmonary Disease (COPD)

The optimal management of COPD requires a staged approach with bronchodilators as the cornerstone of therapy, with treatment intensity increasing based on disease severity, symptom burden, and exacerbation risk. 1

Non-Pharmacological Interventions

• Smoking cessation is the single most important intervention for all COPD patients and should be strongly encouraged at every clinical encounter 1
• Participation in an active smoking cessation program leads to higher sustained quit rates, especially when nicotine replacement therapy is included 2
• Pulmonary rehabilitation programs improve exercise performance, reduce breathlessness, and should be considered for moderate/severe disease 2, 1
• Annual influenza vaccination is recommended for all COPD patients, especially those with moderate to severe disease 2, 1
• Exercise should be encouraged within the limitations of airways obstruction 2
• Nutrition management is important - weight reduction in obese patients will reduce energy requirements, while nutritional support may be needed for malnourished patients with severe COPD 2

Pharmacological Treatment Based on Disease Severity

Mild COPD

• Patients with mild disease and no symptoms require no drug treatment 1
• Symptomatic patients should use short-acting bronchodilators (β2-agonist or anticholinergic) as needed 2, 1
• If these drugs are ineffective, they should be stopped 2

Moderate COPD

• Initial therapy should be a long-acting bronchodilator 2, 3
• Long-acting muscarinic antagonists (LAMAs) are preferred for exacerbation prevention 1, 3
• For persistent breathlessness on monotherapy, the use of two bronchodilators is recommended 2
• A corticosteroid trial should be considered in all patients 2

Severe COPD

• Combination therapy with a regular LABA and LAMA is recommended 2, 1
• For patients who develop additional exacerbations on LABA/LAMA therapy, two options exist:
  • Escalation to LABA/LAMA/ICS (triple therapy) 2
  • Switch to LABA/ICS combination 2
• For patients with severe COPD who still have exacerbations on triple therapy:
  • Consider adding roflumilast for patients with FEV1 <50% predicted and chronic bronchitis 2
  • Consider adding a macrolide in former smokers (with caution regarding resistant organisms) 2
• Long-term oxygen therapy (LTOT) prolongs life in hypoxemic patients (PaO2 <7.3 kPa) 2

Inhaler Selection and Technique

• Inhaler technique must be demonstrated to patients before prescribing and should be regularly checked 1
• Select an appropriate device to ensure efficient delivery 2
• 76% of COPD patients make important errors when using metered-dose inhalers, while 10-40% make errors with dry powder inhalers 1

Management of Exacerbations

• Antibiotics should be used when sputum becomes purulent (7-14 day course) 1
• Systemic corticosteroids (40mg prednisone daily for 5 days) improve lung function and shorten recovery time during exacerbations 1

Common Pitfalls and Caveats

• Beta-blocking agents (including eyedrop formulations) should be avoided in COPD patients 1
• There is no evidence supporting the use of prophylactic antibiotics given continuously or intermittently 2, 1
• There is no role for other anti-inflammatory drugs such as sodium cromoglycate, nedocromil sodium, antihistamines, or mucolytics in COPD 2
• Pulmonary vasodilators have no role in patients with COPD and pulmonary hypertension 2
• ICS increase the risk for developing pneumonia, which should be carefully considered when assessing the risk/benefit ratio of ICS/LABA combinations 2

Special Considerations

• LABA/ICS may be the first choice for initial therapy in patients with a history of asthma-COPD overlap or high blood eosinophil counts 2, 1
• For COPD patients requiring combination therapy with ICS, the recommended dosage is 1 inhalation of fluticasone propionate/salmeterol 250/50 twice daily, approximately 12 hours apart 4
• Non-invasive ventilatory support should be considered for patients with severe nocturnal hypoxemia or respiratory muscle weakness 1