First-Line Inhaler Treatment for Non-Infective AECOPD GOLD E with Raised Eosinophils
For a patient with non-infective acute exacerbation of COPD (AECOPD) GOLD Group E with raised eosinophils, initiate single-inhaler triple therapy (LAMA/LABA/ICS) as first-line treatment. 1
Treatment Algorithm
Initial Therapy Selection
Start with single-inhaler triple therapy (LAMA/LABA/ICS) in symptomatic COPD patients with high risk of exacerbations, particularly when eosinophils are elevated, as this reduces mortality in individuals with moderate-severe disease 1
The 2023 Canadian Thoracic Society guidelines specifically recommend upfront triple therapy for patients with previous history of recurrent moderate or severe exacerbations, which is more proactive than other guidelines 1
Triple therapy is superior to dual therapy (LAMA/LABA alone) in this high-risk population with elevated eosinophils 1
Rationale for ICS Component
Elevated eosinophils predict favorable response to corticosteroids in patients with chronic respiratory symptoms 1
The presence of eosinophilic airway inflammation is causally associated with increased cough sensitivity and responds well to inhaled corticosteroids 1
Blood eosinophil counts ≥ 300 cells/μL specifically indicate patients who should not have ICS withdrawn 1
Device Selection Considerations
Dry powder inhalers (DPIs) should be prioritized when clinically appropriate, as they are as effective as metered-dose inhalers with spacers and have lower environmental impact 1
Patient factors to assess include: inspiratory flow rate, ability to coordinate actuation, hand strength, and patient preference 1
For patients unable to use DPIs during acute exacerbations, have rescue packs of MDI with spacer available 1
Critical Pitfalls to Avoid
Do not start with LAMA/LABA dual therapy alone in patients with elevated eosinophils and exacerbation history, as this misses the mortality benefit of triple therapy 1
Do not use ICS monotherapy - always combine with long-acting bronchodilators (LAMA and/or LABA) for COPD management 1
Do not withdraw ICS in patients with blood eosinophils ≥ 300 cells/μL or those with moderate-high symptom burden and high exacerbation risk, unless significant adverse effects occur 1
Monitoring Response
Reassess symptoms, exacerbation frequency, and eosinophil counts after initiating therapy 1
If symptoms persist despite triple therapy, consider adding oral medications such as azithromycin or N-acetylcysteine rather than increasing ICS dose 1
Monitor for pneumonia risk, which is increased with ICS use (5% vs 3% without ICS), though this must be balanced against the mortality benefit in high-risk patients 2