What is the first line treatment for Gold E Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

The first-line treatment for GOLD E COPD should be a combination of a long-acting muscarinic antagonist (LAMA) and a long-acting beta-agonist (LABA), with the option to add an inhaled corticosteroid (ICS) for patients with a history of exacerbations or severe airflow obstruction. According to the European Respiratory Journal study 1, the majority of guidelines recommend LAMA or LABA as the first treatment choice for patients with COPD, with the addition of ICS for patients with frequent exacerbations or severe airflow obstruction. The study notes that the criteria for the proper use of ICS are roughly similar across guidelines, with ICS recommended in combination with bronchodilators in patients with FEV1 <50% pred, at high risk for exacerbations, and/or with a history of two or more exacerbations in the previous year.

Some key points to consider when selecting a first-line treatment for GOLD E COPD include:

• The patient's symptom burden and exacerbation risk
• The use of LAMA and LABA as the cornerstone of initial therapy
• The potential addition of ICS for patients with a history of exacerbations or severe airflow obstruction
• The importance of individualizing treatment based on patient-specific factors, such as comorbidities and medication tolerance.

As noted in the study 1, the specific medications and dosages may vary depending on the patient's needs and the guidelines being followed. However, the general principle of using a combination of LAMA and LABA, with the option to add ICS, is a key component of first-line treatment for GOLD E COPD.

From the FDA Drug Label

The efficacy of STIOLTO RESPIMAT is based primarily on two 4-week dose-ranging trials in 592 COPD patients and two confirmatory active-controlled 52-week trials (Trials 1 and 2) in 5,162 COPD patients. In both Trials 1 and 2, STIOLTO RESPIMAT demonstrated significant improvements in FEV1 AUC0-3hr and trough FEV1 after 24 weeks compared to tiotropium 5 mcg and olodaterol 5 mcg

First line treatment for Gold E COPD is not explicitly stated in the provided text, however, Tiotropium is mentioned as a treatment option.

• The provided text does discuss the efficacy of STIOLTO RESPIMAT (a combination of tiotropium and olodaterol) in treating COPD patients.
• Tiotropium is compared to olodaterol and the combination STIOLTO RESPIMAT in the clinical trials. 2

From the Research

Gold E COPD First Line Treatment

• The first line treatment for Gold E COPD patients is not explicitly stated in the provided studies, but the studies suggest that a combination of medications may be effective in managing the disease.
• A study published in 2023 3 found that combination therapy with a long-acting muscarinic antagonist (LAMA) and a long-acting beta-agonist (LABA) may be beneficial for patients with moderate to severe COPD.
• Another study published in 2020 4 suggested that triple therapy, which includes a LAMA, a LABA, and an inhaled corticosteroid (ICS), may be considered as first-line treatment for patients with more than 2 times moderate to severe exacerbations of COPD in the previous year and who have blood eosinophil counts ≥100 cells/μL, reduced lung function (FEV1 ≤ 42%), and more symptoms (CAT score ≥ 18).
• A study published in 2025 5 found that patients with COPD in GOLD group E should be further stratified to determine the appropriate initial inhalation therapy, and that a combination of LABA and LAMA or LABA, LAMA, and ICS may be beneficial for patients with FEV1%pred <50% and CAT≥10.
• A study published in 2019 6 found that once-daily LABA/LAMA combinations via a single inhaler are associated with a clinically significant improvement in lung function and health-related quality of life in patients with mild-to-moderate COPD.
• A study published in 2008 7 found that combination therapy with salmeterol/fluticasone and tiotropium leads to better control of symptoms and improved lung function, with no greater risk of side-effects, as compared to salmeterol/fluticasone or tiotropium alone in the treatment of COPD.

Key Findings

• Combination therapy with LAMA and LABA may be beneficial for patients with moderate to severe COPD 3.
• Triple therapy may be considered as first-line treatment for patients with more than 2 times moderate to severe exacerbations of COPD in the previous year and who have blood eosinophil counts ≥100 cells/μL, reduced lung function (FEV1 ≤ 42%), and more symptoms (CAT score ≥ 18) 4.
• Patients with COPD in GOLD group E should be further stratified to determine the appropriate initial inhalation therapy 5.
• Once-daily LABA/LAMA combinations via a single inhaler are associated with a clinically significant improvement in lung function and health-related quality of life in patients with mild-to-moderate COPD 6.
• Combination therapy with salmeterol/fluticasone and tiotropium leads to better control of symptoms and improved lung function, with no greater risk of side-effects, as compared to salmeterol/fluticasone or tiotropium alone in the treatment of COPD 7.