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

COPD Treatment Management

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

Initial Assessment and Classification

• COPD patients should be classified based on symptom burden and exacerbation risk to guide appropriate therapy 2
• Smoking cessation is the single most important intervention for all COPD patients and should be strongly encouraged at every clinical encounter 1

Pharmacological Treatment Algorithm

Group A (Low symptoms, Low exacerbation risk)

• Short-acting bronchodilator (SABA or SAMA) as needed for symptom relief 3
• No maintenance therapy required if minimal symptoms 2

Group B (High symptoms, Low exacerbation risk)

• Initial therapy should be a long-acting bronchodilator (LABA or LAMA) 2
• Long-acting bronchodilators are superior to short-acting bronchodilators taken intermittently 2
• For patients with persistent breathlessness on monotherapy, the use of two bronchodilators (LABA/LAMA) is recommended 2
• For patients with severe breathlessness, initial therapy with two bronchodilators may be considered 2

Group C (Low symptoms, High exacerbation risk)

• A LAMA is preferred for exacerbation prevention based on comparison to LABAs 2
• Consider roflumilast in patients with chronic bronchitis phenotype 2

Group D (High symptoms, High exacerbation risk)

• LABA/LAMA combination is recommended as first-line therapy due to:

  • Superior results in patient-reported outcomes compared with a single bronchodilator 2
  • Superior efficacy compared to LABA/ICS in preventing exacerbations 2
  • Lower risk of pneumonia compared to ICS-containing regimens 2

• If a single bronchodilator is initially chosen, a LAMA is preferred for exacerbation prevention 2

Treatment Escalation

• For patients who develop additional exacerbations on LABA/LAMA therapy, consider:

  • Escalation to LABA/LAMA/ICS triple therapy 2
  • Switch to LABA/ICS (particularly in patients with asthma-COPD overlap or high blood eosinophil counts) 2, 1

• If patients on triple therapy still have exacerbations, consider:

  • Adding roflumilast in patients with FEV1 <50% predicted and chronic bronchitis, particularly with history of hospitalization 2
  • Adding a macrolide in former smokers (consider risk of antimicrobial resistance) 2

Specific Medication Considerations

• For LABA/ICS combinations, the recommended dosage for COPD is 1 inhalation of fluticasone propionate/salmeterol 250/50 mcg twice daily 4
• LABA/ICS combinations may reduce exacerbations of COPD in patients with a history of exacerbations 4
• LABA/LAMA combinations have been shown to be superior to LABA/ICS in preventing exacerbations in high-risk patients 5
• ICS use increases risk of pneumonia, especially in current smokers, older patients, and those with prior pneumonia 3

Non-Pharmacological Management

• Pulmonary rehabilitation is recommended for patients with high symptom burden (Groups B, C, and D) 1
• Programs should include physiotherapy, muscle training, nutritional support, and education 1
• A combination of constant load or interval training with strength training provides better outcomes than either method alone 2

Exacerbation Management

• Short-acting inhaled β2-agonists, with or without short-acting anticholinergics, are recommended as initial bronchodilators for acute exacerbations 2
• Systemic corticosteroids improve lung function and shorten recovery time during exacerbations 2
• Antibiotics should be used when sputum becomes purulent (7-14 day course) 1
• Maintenance therapy with long-acting bronchodilators should be initiated as soon as possible before hospital discharge 2

Advanced Treatment Options

• For patients with severe COPD and emphysema, consider:
  • Lung volume reduction procedures in selected patients 2
  • Lung transplantation in very severe COPD without relevant contraindications 2

Common Pitfalls and Caveats

• Beta-blocking agents (including eyedrop formulations) should be avoided in COPD patients 1
• Inhaler technique must be demonstrated to patients before prescribing and should be regularly checked 1
• Methylxanthines are not recommended for exacerbations due to side effects 2
• There is no evidence supporting the use of prophylactic antibiotics given continuously or intermittently 1
• Antitussives cannot be recommended for COPD 2