Pharmacotherapy for COPD
Approach to Therapy | Dyspnea Without Exacerbations | Exacerbations With or Without Dyspnea |
|---|---|---|
Initial therapy* | LABA or LAMA | LABA or LAMA |
Initial escalation of therapy | LABA + LAMA | LABA + LAMA or LABA + LAMA + ICS† |
Subsequent approach to therapy for persistent symptoms | Consider changing inhaler device or medication Implement or escalate non-pharmacological treatments Evaluation for other causes of dyspnea | LABA + LAMA + ICS + roflumilast or azithromycin‡ |
* Rescue short-acting bronchodilators should be prescribed to all patients for immediate symptom relief. | ||
† ICS is most effective in patients with eosinophilia ≥ 150/mcL (≥ 0.15 × 109/L). May need to de-escalate ICS if the patient develops pneumonia or does not respond to treatment. In patients with eosinophilia ≥ 300 mcL (≥ 0.30 × 109/L), de-escalation is more likely to cause an exacerbation. | ||
‡ For recurrent exacerbations, add either a phosphodiesterase-4 (PDE4) inhibitor (eg, roflumilast) or long-term azithromycin. Roflumilast is indicated in patients with COPD (FEV1< 50%) with chronic bronchitis. Azithromycin is preferred for former smokers and is less effective in current smokers. If exacerbations persist, patients with eosinophilia may benefit from a biologic such as mepolizumab or dupilumab. | ||
FEV1 = The volume of air forcefully expired during the first second after taking a full breath; LABA = long-acting beta agonist; LAMA = long-acting antimuscarinic antagonist; ICS = inhaled corticosteroid (glucocorticoid). | ||
Adapted from the Global Initiative for Chronic Obstructive Lung Disease (GOLD): Global Strategy for the Prevention, Diagnosis, and Management of COPD: 2026 report. Available at http://www.goldcopd.org. | ||
