This post is based on Chapter 4 [Management of STABLE COPD (pp 81 – )] of the GOLD 2017 COPD guidelines for the management of stable COPD. Resource (1).
Assessment of COPD
GOLD 2017 on p 34 – 36 (pp 50 – 52 of the PDF):
There are three aspects to COPD assessment: the spirometry grade based on the FEV1 (see table above) and the A-B-C-D* symptom assessment tool, and finally the number of exacerbations.
For details on spirometric assessment, the A-B-C-D symptom assessment tool, and the number of exacerbations (per year), see Assessment Of The Severity Of COPD From The GOLD 2017 COPD Guidelines Posted on July 20, 2017.
For details on the symptom scores that can be used in following COPD, see my post Symptom Scores For Monitoring COPD Posted on July 19, 2017.
It is important to realize that prognosis in COPD is best estimated by the BODE index. For details on use of the BODE index please see Determining Prognosis In COPD – The BODE Index Posted on July 12, 2017
For a chart covering all of the medications used in COPD, please see the post A List of Medications Used In The Treatment Of COPD Posted on August 6, 2017.
Abbreviations Used In The Post:
LAMA – long acting muscarinic antagonist
LABA – long acting beta agonist
ICS – inhaled corticosteroid
Summary of the management of stable COPD:
The management of stable COPD is based predominantly on the individual assessment of symptoms and on the risk of future exacerbations.
Smoking cessation is the most important part of COPD therapy.
Treatment goals for COPD are the reduction of symptoms and also the reduction of future risk of exacerbations.
Nonpharmacologic therapy should be included as well as pharmacologic therapy.
Goals for the treatment of stable COPD are to:
1. Relieve symptoms
2. Improve exercise tolerance
3. Improve health status
4. Prevent disease progression
5. Prevent and treat exacerbations
6. Reduce mortality
Key points on drug inhalation therapy
1. The most important reason to choose a given inhalation device is patient ability and preference.
2. Proper instruction on how to use the inhaler device is critical to therapeutic success
3. Make sure that the patient is using the inhaler properly before concluding that it is not working.
Key points on bronchodilators
1. LABAs and LAMAs are better than short acting agents except for patients who only have occasional dyspnea.
2. Patients can be started on a single long acting bronchodilator therapy.
3. Patients with persistent dyspnea while on one bronchodilator should be escalated to two different bronchodilators.
4. Inhaled bronchodilators are preferred over oral bronchodilators.
5. Theophylline should not be used unless other long-term bronchodilators are unavailable or are unaffordable.
Key points on anti-inflammatory agents
1. Long-term monotherapy is not recommended with ICS
2. Long-term treatment with ICS may be considered in association with LAMAs for patients with a history of exacerbations despite appropriate treatment with long-acting bronchodilators.
3. Long-term therapy with oral corticosteroids is not recommended.
4. In patients with exacerbations despite LABA/ICS or LABA/LAMA/ICS, chronic bronchitis and severe to very severe airflow obstruction, adding a PDE4 inhibitor may be considered.
5. In former smokers with exacerbations despite appropriate therapy, macrolides can be considered.
6. Statin therapy is not recommended to prevent exacerbations.
7. Antioxidant mucolytics are to be used only in selected patients.
Key points for other pharmacologic agents
1. Patients with severe hereditary alpha-1 anti-trypsin efficiency and established emphysema may be considered for alpha-1 antitrypsin therapy.
2. Antitussives are not recommended.
3. Drugs approved primary pulmonary hypertension are not recommended for pulmonary hypertension secondary to COPD.
4. In patients with severe COPD, low-dose long-acting oral and parenteral opioids can be considered to treat the dyspnea.
5. Be sure the patient understands the treatment program [meaning the goals of the program, how to use the medications, and how the results of the program are assessed].
Pharmacologic treatment algorithms
Algorithm for group A patients:
1. All patients should be given a bronchodilator trial.
2. Bronchodilator can be either a long acting or short acting.
3. The response to the bronchodilator should be evaluated based on symptom relief.
4. Based on the evaluation of symptom relief, the bronchodilator may be continued, or an alternate bronchodilator class may be tried, or the bronchodilator may be discontinued.
Algorithm for group B patients:
1. In these patients a long acting bronchodilator (a LAMA or a LABA) should be prescribed as initial therapy because these are superior to short acting bronchodilators taken PRN.
2. There is no evidence to recommend either a LAMA or a LABA over the other class for group B. The class chosen should be based on the patient’s perception of symptom relief.
3. In patients on monotherapy who continue to have symptoms, use two bronchodilators.
4. For group B patients with severe breathlessness consider initial therapy using two bronchodilators (i.e., a LABA and a LAMA together).
5. If adding the second bronchodilator does not improve symptoms, the patient should be stepped back down to a single bronchodilator.
6. It’s important to remember that group B patients like other patients with COPD are likely to have important comorbidities such as cardiac disease or renal disease or other chronic diseases and to be alert for that possibility.
Algorithm for group C patients:
1. Initial therapy consists of a single long acting bronchodilator. Studies have suggested that a LAMA is superior to a LABA for preventing exacerbations. So in group C patients, start with a LAMA.
2. Patients who have persistent exacerbations on a single long acting bronchodilator may benefit from having a second long acting bronchodilator added (LABA/LAMA).
3. The combination of a long-acting beta agonist plus an inhaled corticosteroid (LABA/ICS) could be chosen for a patient who does not respond to a single bronchodilator. However, an ICS increases the risk for developing pneumonia in some patients and therefore it is best to start with a LABA/LAMA first.
Algorithm for group D patients:
1. GOLD recommends starting therapy with a LABA/LAMA combination. This is because:
- Using patient reported outcomes [meaning symptom scorres], the LABA/LAMA combination showed superior results as compared to a single therapeutic agent.
- If a single bronchodilator is used as the initial treatment, a LAMA is better for preventing acute exacerbations as compared to a LABA alone. A LABA/LAMA combination was better than a LABA/ICS combination for preventing exacerbations and for other patient reported outcomes in group D.
- Group D patients when given treatment with ICS are at higher risk of developing pneumonia.
2. “In some patients initial therapy with LABA/ICS may be the first choice. These patients may have a history and/or findings suggestive of asthma – COPD overlap.”
3. If a group D patient develops further exacerbations on LABA/LAMA therapy then consider to one of two alternate pathways:
- Escalate therapy to LABA/LAMA/ICS. The effectiveness of this strategy is not yet known.
- Change from a LABA/LAMA inhaler to a LAMA/ICS. But there’s actually no evidence that this helps impact exacerbations or symptoms.
4. When patients treated with LABA/LAMA/ICS are still having exacerbations then consider the following options:
- “Add roflumilast. This may be considered in patients with an FEV1 of less than 50 percent predicted and chronic bronchitis, particularly if they had experienced at least one hospitalization for exacerbation in the previous year.”
- “Add a macrolide. The best available evidence exists for the use of azithromycin. Consideration to the development of resistant organisms should be factored into decision-making.”
- Stop the ICS. This is recommended because there is no evidence for efficacy and there is an elevated risk of adverse side effects which include pneumonia. Finally, there is evidence that shows that there is no significant harm from stopping the ICS.
COPD patients who are malnourished should receive nutritional supplementation.
Long-term oxygen therapy is indicated for stable patients who have:
- PaO2 at or below 55 mm Hg or an SaO2 at or below 88%, with or without hypercanpna confirmed twice over a three-week period; or
- PaO2 between 55 mm Hg and 60 mm Hg, or in Sa02 of 88%, if there is evidence of hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit greater than 55%).
Once placed on long-term oxygen therapy (LTOT) the patient should be reevaluated after 60 to 90 days with repeat arterial blood gas (ABG) or oxygen saturation while inspiring the same level of oxygen bear to determine if oxygen is therapeutic and still indicated, respectively.
For Non-Pharmacologic Treatment and Monitoring and Follow up please see the GOLD 2017 Guidelines pp 87 – 96.
(1) The Global Initiative For Chronic Obstructive Lung Disease has published GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD[Download link to PDF] and the POCKET GUIDE TO COPD DIAGNOSIS, MANAGEMENT, AND PREVENTION: A Guide for Health Care Professionals 2017 REPORT [Link is to the PDF]