From the Guidelines
For GOLD E class COPD, the first-line treatment should be a combination of a long-acting muscarinic antagonist (LAMA) and a long-acting beta-agonist (LABA) in a single inhaler, as recommended by the most recent guidelines 1. This approach is based on the latest evidence from the 2018 GOLD report, which emphasizes the importance of combining bronchodilators to improve symptoms and reduce exacerbations in patients with high symptom burden and high exacerbation risk. The following LAMA/LABA combinations are commonly used:
- Umeclidinium/vilanterol (Anoro Ellipta)
- Tiotropium/olodaterol (Stiolto Respimat)
- Glycopyrrolate/formoterol (Bevespi Aerosphere)
- Glycopyrrolate/indacaterol (Utibron Neohaler) If the patient continues to have exacerbations despite LAMA/LABA therapy, escalation to triple therapy by adding an inhaled corticosteroid (ICS) is recommended, with options including fluticasone/umeclidinium/vilanterol (Trelegy Ellipta) or beclomethasone/formoterol/glycopyrrolate (Breztri Aerosphere) 1. Additionally, patients should receive pneumococcal and annual influenza vaccinations, smoking cessation support if applicable, and pulmonary rehabilitation to optimize their functional status and quality of life. It's worth noting that the 2016 review of national guidelines for management of COPD in Europe also supports the use of LAMA/LABA combinations as a first-line treatment for patients with high symptom burden and high exacerbation risk 1.
From the Research
First Line Treatment for GOLD E Class COPD
The first line treatment for GOLD E class COPD involves the use of inhalation therapies. According to the study 2, patients with COPD in GOLD group E should be further stratified to determine the appropriate initial inhalation therapy.
- The study 2 found that patients treated with LABA + LAMA or LABA + LAMA + ICS had a lower incidence of exacerbations and frequent exacerbations compared with the patients treated with LAMA or LABA + ICS in the FEV1%pred <50% and CAT≥10 groups.
- Another study 3 compared the benefits and harms of LAMA+LABA versus LABA+ICS for treatment of people with stable COPD, and found that combination LAMA+LABA therapy probably holds similar benefits to LABA+ICS for exacerbations and quality of life.
- The study 4 presents the clinical evidence that led to the approval of triple therapies, and discusses the role of ICS in patients with COPD. It found that triple therapy decreased the risk of exacerbations and improved lung function and health status, with a favorable benefit-to-harm ratio.
- Other studies 5, 6 also support the use of combination therapies, such as formoterol and tiotropium, or glycopyrrolate and formoterol fumarate, for the treatment of COPD.
Treatment Options
The treatment options for GOLD E class COPD include:
- LABA + LAMA
- LABA + LAMA + ICS
- LAMA + ICS
- Glycopyrrolate and formoterol fumarate
- Formoterol and tiotropium
These treatment options may have different effects on lung function, exacerbations, and quality of life, and the choice of treatment should be individualized based on the patient's specific needs and characteristics.