What should be done for a patient's chronic obstructive pulmonary disease (COPD) maintenance therapy?

COPD Maintenance Therapy

All symptomatic COPD patients should receive long-acting bronchodilator maintenance therapy, with treatment intensity escalated based on exacerbation risk, symptom burden, and lung function impairment. 1

Treatment Algorithm Based on Disease Severity and Risk

Patients with Low Exacerbation Risk

• LAMA/LABA dual therapy is the preferred maintenance regimen for patients with moderate to severe COPD who have fewer than 2 moderate exacerbations or 1 severe exacerbation in the past year 1
• This dual bronchodilator approach is superior to monotherapy with either LAMA or LABA alone for improving lung function, symptoms, and quality of life 1
• Single-inhaler dual therapy is preferred over multiple inhalers to improve adherence and reduce technique errors 1

Patients with High Exacerbation Risk

Triple therapy with LAMA/LABA/ICS is strongly recommended for patients meeting ALL of the following criteria: 1, 2

• ≥2 moderate exacerbations OR ≥1 severe exacerbation requiring hospitalization in the past year 1
• High symptom burden (CAT ≥10 or mMRC ≥2) 1, 2
• FEV1 <80% predicted 1, 2

The evidence supporting triple therapy is compelling: the IMPACT and ETHOS trials demonstrated significant mortality reduction with triple therapy versus LAMA/LABA dual therapy (hazard ratios of 0.64 and 0.54 respectively), along with reduced exacerbations, improved lung function, and better health status 1. Notably, triple therapy did not show mortality benefit over ICS/LABA, but the comprehensive benefits across multiple outcomes support its use in this high-risk population 1.

Critical Considerations for ICS-Containing Regimens

• Never use ICS monotherapy for COPD—this approach is not recommended and lacks supporting evidence 1, 2
• Triple therapy increases pneumonia risk, but the benefit-risk ratio remains favorable: number needed to treat is 4 to prevent one exacerbation versus number needed to harm of 33 to cause one pneumonia 2
• Monitor all patients on ICS-containing regimens for signs of pneumonia, oral candidiasis, and upper respiratory tract infections 1

Rescue Medication

• All patients across the COPD severity spectrum should have short-acting bronchodilator (SABD) therapy available for as-needed use 1
• Increasing frequency of rescue medication use signals inadequate disease control and warrants reassessment of maintenance therapy 2

Single Inhaler Triple Therapy (SITT) Advantages

When prescribing triple therapy, use a single-inhaler formulation rather than multiple separate inhalers 1, 2. This approach offers:

• Improved medication adherence 1
• Reduced risk of inhaler technique errors 1
• Potential for enhanced therapeutic benefits 1

Common Pitfalls to Avoid

• Do not delay escalation to triple therapy in patients meeting high-risk criteria—the mortality benefit demonstrated in IMPACT and ETHOS trials was specific to patients with the defined risk profile 1
• Do not use ICS/LABA dual therapy without a LAMA in high-risk patients, as triple therapy showed superior outcomes 1
• Do not prescribe LABA monotherapy, as dual bronchodilation with LAMA/LABA is more effective 1

Adjunctive Therapies for Refractory Disease

For patients with persistent exacerbations despite optimal inhaled therapy: 1

• Roflumilast may be considered in patients with moderate to severe COPD, chronic bronchitis, and ≥1 exacerbation in the previous year, though side effects (weight loss, diarrhea) may limit tolerability 1
• N-acetylcysteine can be considered in patients with ≥2 exacerbations in the previous 2 years on maximal inhaled therapy, with minimal adverse effects 1
• Theophylline is a lower-priority option due to narrow therapeutic window and drug interaction concerns, requiring careful monitoring 1