Inhaler Treatment for COPD, Asthma, and Both
COPD Inhaler Therapy
For patients with COPD and moderate-to-high symptoms (CAT ≥10 or mMRC ≥2) and impaired lung function (FEV₁ <80%), start with LAMA/LABA dual bronchodilator therapy as initial maintenance treatment. 1, 2
Initial Treatment Algorithm for COPD
Mild COPD (low symptoms, FEV₁ ≥80%): Start with LAMA or LABA monotherapy plus short-acting bronchodilator as needed 1, 2
Moderate-to-severe COPD (CAT ≥10, mMRC ≥2, FEV₁ <80%): Start with LAMA/LABA dual therapy 1, 2
High exacerbation risk (≥2 moderate exacerbations or ≥1 severe exacerbation requiring hospitalization/ED visit in past year): Start with LAMA/LABA/ICS triple therapy 1
Critical Safety Point for COPD
LAMA/LABA dual therapy is strongly preferred over ICS/LABA combination therapy because it provides superior lung function improvements with significantly lower pneumonia rates. 1, 2 ICS monotherapy is never recommended in COPD and provides no benefit—ICS should only be used as part of combination therapy. 1, 2
Treatment Escalation in COPD
If patients on LAMA/LABA continue having exacerbations, escalate to LAMA/LABA/ICS triple therapy (preferably single-inhaler triple therapy) 1
For patients with FEV₁ <50% predicted with chronic bronchitis who were hospitalized for exacerbation in the past year, consider adding roflumilast 1
In former smokers with persistent exacerbations, consider adding prophylactic macrolide therapy, weighing the risk of resistant organisms 1
Asthma Inhaler Therapy
For patients with asthma not adequately controlled on ICS monotherapy, use ICS/LABA combination therapy. 3
Asthma Treatment by Age and Severity
Adults and adolescents ≥12 years: ICS/LABA combination (fluticasone/salmeterol 100/50,250/50, or 500/50) one inhalation twice daily, with dosage based on asthma severity and previous ICS dose 3
Children 4-11 years: ICS/LABA 100/50 one inhalation twice daily for patients not controlled on ICS alone 3
Maximum dose: ICS/LABA 500/50 twice daily 3
Critical Safety Warning for Asthma
LABA monotherapy (without ICS) is contraindicated in asthma because it increases the risk of asthma-related death, hospitalization, and intubation. 3 LABA must always be combined with ICS in asthma treatment. 3
Rescue Therapy
All patients should have a short-acting beta2-agonist (SABA) for immediate relief of acute symptoms between scheduled doses 3
Patients should never use more than one inhalation twice daily of their maintenance ICS/LABA inhaler 3
COPD-Asthma Overlap (Both Conditions)
For patients with both COPD and concomitant asthma, ICS/LABA combination therapy is preferred over LAMA/LABA dual therapy. 1 This is the only scenario where ICS-containing therapy should be considered in patients without frequent COPD exacerbations. 1, 2
Common Pitfalls to Avoid
Never prescribe ICS monotherapy in COPD—it provides no benefit and is explicitly not recommended 1, 2
Never prescribe LABA monotherapy in asthma—it significantly increases mortality risk 3
Do not delay dual bronchodilator therapy in symptomatic COPD patients (CAT ≥10, mMRC ≥2)—evidence consistently shows LAMA/LABA is superior to monotherapy 2
Avoid long-term oral corticosteroids in stable COPD—they are not recommended 1
Do not use short-acting bronchodilators alone for maintenance therapy—long-acting agents should be initiated early 2
Avoid theophylline as initial therapy due to equivocal benefits and significant adverse event risk 2
Practical Implementation
After inhalation, patients should rinse their mouth with water without swallowing to reduce the risk of oral candidiasis 3
Reassess symptom burden and exacerbation frequency at 2-4 weeks after initiating therapy 2, 3
Verify proper inhaler technique at each visit, as incorrect use leads to poorly controlled disease 1
For COPD patients on triple therapy with moderate-to-high symptom burden (CAT ≥10) or FEV₁ <80%, continue triple therapy rather than stepping down to dual therapy 1