Create an Rx‑format prescription for an adult with stable chronic obstructive pulmonary disease (COPD).

Prescription for Stable COPD in an Adult

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Patient Name: ________________________________
Date: ________________
DOB: ________________

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℞ Primary Maintenance Therapy

Tiotropium (Spiriva Respimat) 2.5 mcg

• Sig: Inhale 2 puffs (5 mcg total) once daily
• Disp: 1 inhaler (60 actuations)
• Refills: 11

OR

Umeclidinium/Vilanterol (Anoro Ellipta) 62.5 mcg/25 mcg

• Sig: Inhale 1 puff once daily
• Disp: 1 inhaler (30 doses)
• Refills: 11

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℞ Rescue Therapy

Albuterol (ProAir HFA) 90 mcg/actuation

• Sig: Inhale 2 puffs every 4-6 hours as needed for shortness of breath
• Disp: 1 inhaler (200 actuations)
• Refills: 3

1, 3

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℞ For High-Risk Patients (≥2 moderate or ≥1 severe exacerbation in past year)

Fluticasone/Salmeterol (Advair Diskus) 250 mcg/50 mcg

• Sig: Inhale 1 puff twice daily (morning and evening, 12 hours apart)
• Disp: 1 inhaler (60 doses)
• Refills: 11

OR

Fluticasone/Umeclidinium/Vilanterol (Trelegy Ellipta) 100 mcg/62.5 mcg/25 mcg

• Sig: Inhale 1 puff once daily
• Disp: 1 inhaler (30 doses)
• Refills: 11

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℞ For Persistent Exacerbations Despite Triple Therapy (with chronic bronchitis phenotype)

Azithromycin 250 mg tablets

• Sig: Take 1 tablet (250 mg) three times weekly (e.g., Monday, Wednesday, Friday)
• Disp: 52 tablets
• Refills: 3

Note: Obtain baseline ECG (QTc must be <450 ms in men, <470 ms in women), liver function tests, and sputum culture for nontuberculous mycobacteria before initiating. Recheck ECG and LFTs at 1 month, then every 6 months. 1

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Prescriber Signature: ________________________________
DEA #: ________________
NPI #: ________________

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Instructions:

• Use spacer device with metered-dose inhalers
• Rinse mouth after inhaled corticosteroid use
• Continue smoking cessation efforts
• Pulmonary rehabilitation referral recommended

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