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

Recommended Medications for COPD Treatment

For patients with COPD, a stepwise approach using bronchodilators as the foundation of therapy is recommended, with treatment escalation based on symptom burden and exacerbation risk. 1

Initial Treatment Based on COPD Classification

• For patients with low symptoms and low exacerbation risk (GOLD Group A):

  • Start with a short-acting bronchodilator (SABA or SAMA) as needed for symptom relief 1, 2

• For patients with moderate to high symptoms (mMRC ≥2, CAT ≥10) and low exacerbation risk (GOLD Group B):

  • First-line treatment with a long-acting bronchodilator (LABA or LAMA) 1
  • LAMAs are preferred over LABAs due to superior efficacy in reducing exacerbations 2

• For patients with moderate to high symptoms and high exacerbation risk (GOLD Group D):

  • LAMA/LABA combination therapy is recommended as initial treatment 1, 3
  • LAMA/LABA combinations provide superior bronchodilation, symptom relief, and exacerbation prevention compared to monotherapy 3, 4

Treatment Escalation for Persistent Symptoms or Exacerbations

• For patients with persistent breathlessness on monotherapy:

  • Escalate to LAMA/LABA dual therapy 1
  • LAMA/LABA combinations show superior results compared to single bronchodilators in patient-reported outcomes 1, 5

• For patients with persistent exacerbations on LAMA/LABA therapy:

  • Consider escalation to triple therapy (LAMA/LABA/ICS) 1, 3
  • Triple therapy improves lung function, quality of life, and reduces exacerbation rates compared to dual therapy 3, 6
  • Single inhaler triple therapy (SITT) is preferred over multiple inhalers 1

Additional Treatments for Specific Phenotypes

• For patients with chronic bronchitis, severe to very severe COPD, and persistent exacerbations despite optimal therapy:

  • Consider adding roflumilast (PDE4 inhibitor) if FEV₁ <50% predicted 1, 3
  • Roflumilast improves lung function and reduces moderate and severe exacerbations 1

• For patients with frequent exacerbations despite optimal inhaled therapy:

  • Consider adding a macrolide (azithromycin or erythromycin) in former smokers 1
  • Long-term azithromycin and erythromycin therapy reduces exacerbations over 1 year 1
  • Be aware of increased risk of bacterial resistance and hearing impairment with azithromycin 1

• For patients with chronic bronchitis and frequent exacerbations:

  • Consider mucolytic agents (N-acetylcysteine, carbocysteine) 1
  • Regular use may reduce exacerbations in select populations 1

Important Clinical Considerations

• ICS monotherapy is not recommended for COPD treatment 1, 2

  • ICS should only be used in combination with bronchodilators 2

• ICS-containing regimens increase the risk of pneumonia, especially in older patients and those with severe disease 3, 7

  • Some evidence suggests different pneumonia risk profiles among ICS options, with potentially lower risk with budesonide compared to fluticasone propionate 7

• Long-term use of oral glucocorticoids has numerous side effects with no evidence of benefits and should be avoided 1

• For patients with severe hereditary alpha-1 antitrypsin deficiency and established emphysema:

  • Consider alpha-1 antitrypsin augmentation therapy 1

Non-Pharmacological Management

• Smoking cessation is essential for all current smokers with COPD 1, 3

• Pulmonary rehabilitation is recommended for patients with high symptom burden (groups B, C, and D) 1, 3

  • Should include a combination of constant load or interval training with strength training 3

• Annual influenza vaccination and pneumococcal vaccination are recommended for all COPD patients 3, 2

Medication Delivery Considerations

• The inhaled route is preferred for bronchodilators and corticosteroids 1
• Proper inhaler technique should be taught at first prescription and checked periodically 1
• During acute exacerbations, nebulizers may be easier for breathless patients to use 1

By following this evidence-based approach to COPD medication management, clinicians can optimize symptom control, reduce exacerbation risk, and improve quality of life for patients with COPD.