What are the initial management recommendations for Chronic Obstructive Pulmonary Disease (COPD) according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2025 guidelines?

Initial Management Recommendations for COPD According to GOLD 2025 Guidelines

The initial management of COPD should follow a stepwise approach based on symptom burden and exacerbation risk, with LABA/LAMA combination therapy recommended as first-line treatment for most symptomatic patients (GOLD Groups B, D, and E). 1, 2

Risk Factor Reduction

• Smoking cessation is the most important intervention and should be continuously encouraged for all current smokers with COPD 3
• Reduction of exposure to other risk factors (occupational dusts, indoor/outdoor air pollution) should be implemented 1

Pharmacological Management by GOLD Group

Group A (Low Symptoms, Low Risk)

• Initial therapy: Short-acting bronchodilator (SABA or SAMA) as needed 1
• Can be either short-acting or long-acting bronchodilator based on patient preference 3
• Continue, stop, or try alternative class of bronchodilator based on symptomatic response 3
• For persistent exacerbations, consider adding a second long-acting bronchodilator (LABA/LAMA) 3

Group B (High Symptoms, Low Risk)

• Initial therapy: Long-acting bronchodilator (LABA or LAMA) 1
• No evidence favoring one class over another; choice depends on individual patient response 3
• For persistent breathlessness on monotherapy, use two bronchodilators (LABA/LAMA) 3
• For severe breathlessness, consider initial therapy with two bronchodilators 3

Group C (Low Symptoms, High Risk)

• Initial therapy: LAMA (preferred over LABA for exacerbation prevention) 3
• For further exacerbations: Consider LAMA+LABA or switch to LABA+ICS 3
• Consider roflumilast if FEV1 <50% predicted and patient has chronic bronchitis 3

Group D (High Symptoms, High Risk)

• Initial therapy: LABA/LAMA combination 3, 1
• Rationale:
  • Superior patient-reported outcomes compared to single bronchodilator 3
  • Superior to LABA/ICS in preventing exacerbations 3
  • Lower risk of pneumonia compared to ICS-containing regimens 3
• If single bronchodilator is chosen initially, LAMA is preferred 3
• LABA/ICS may be first choice for patients with:
  • Asthma-COPD overlap features 3, 1
  • High blood eosinophil counts (≥300 cells/μL) 4

Treatment Escalation for Persistent Exacerbations

For patients with additional exacerbations on LABA/LAMA therapy, two pathways are recommended:

• Escalation to LABA/LAMA/ICS (triple therapy) 3
• Switch to LABA/ICS; if not effective, add LAMA 3

For patients still experiencing exacerbations on triple therapy:

• Consider adding roflumilast for patients with FEV1 <50% predicted and chronic bronchitis, particularly with history of hospitalization 3
• Consider adding a macrolide in former smokers (with caution regarding antibiotic resistance) 3
• Consider stopping ICS if adverse effects occur (e.g., pneumonia) 3

Non-Pharmacological Management

• Pulmonary rehabilitation for all symptomatic patients (Groups B, C, and D) 1
• Exercise training combining constant/interval training with strength training 3
• Education and personalized self-management strategies 3
• Annual influenza vaccination and pneumococcal vaccination 1
• Oxygen therapy for patients with resting hypoxemia 1

Important Clinical Considerations

• ICS monotherapy is not recommended in COPD 3, 1
• Long-term oral corticosteroid therapy is not recommended 3
• LABA/LAMA combinations are increasingly preferred as initial therapy, even in maintenance therapy-naïve patients 2, 5
• Consider comorbidities when selecting treatment, particularly cardiovascular disease with high-dose beta-agonists 1
• Regular follow-up is essential to assess treatment response and adjust therapy 1

Specific Therapies for Special Situations

• Alpha-1 antitrypsin augmentation therapy for patients with severe hereditary deficiency and established emphysema 3
• Low-dose long-acting opioids may be considered for dyspnea in severe disease 3
• Antitussives are not recommended 3
• Drugs approved for pulmonary hypertension are not recommended for pulmonary hypertension secondary to COPD 3