Practical Recommendations for COPD: Evidence-Based Care
The treatment of patients with chronic obstructive pulmonary disease (COPD) depends on symptoms and history of exacerbation. These elements define the treatment strategies within the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Guidelines' ABCD assessment tool
• Although not taken into account in the ABCD tool, spirometry remains important for the diagnosis and assessment of airflow limitation.
Bronchodilators are first-line treatment, either as a single or dual bronchodilator treatment.
• The recently available combination of a long-acting beta agonist (LABA) and a long-acting muscarinic receptor antagonist (LAMA) into a single inhaler has demonstrated improvement in lung function, either in combination or with monotherapy.
In the SPARK study evaluating indacaterol/glycopyrrolate vs glycopyrronium and tiotropium (LABA/LAMA vs LAMA alone) for the prevention of exacerbation in patients with COPD, the combination therapy was superior to a single bronchodilator as measured by the reduction of exacerbations.
• LABA/LAMA was also shown to be superior in the ILLUMINATE study, which compared the patient-reported outcomes and the transition dyspnea index (TDI) for patients on LABA/LAMA with patients on LABA/ICS (inhaled corticosteroid).
Data from multiple studies show that ICS-containing regimens can also effectively reduce exacerbation rates.
Data from post-hoc analyses of clinical trials suggest that patients with high levels of blood eosinophils may respond better to ICS therapy, whereas patients with very low levels of eosinophils may not respond.
ICS therapy is associated with serious side effects, such as pneumonia.
In the WISDOM trial, patients who discontinued ICS experienced approximately 40 mL in forced expiratory volume over 1 second (FEV1), indicating that ICS should be withdrawn very carefully in some patients.
As exacerbations are more frequent and often more severe in winter months, it is recommended to not withdraw steroids during that period
Current evidence suggests that the combination of LABA/LAMA with ICS into a single inhaler will improve lung function, exacerbations, and symptoms
Other treatment options besides triple therapy exist for patients who still experience exacerbations after LABA/LAMA treatment.
• Roflumilast may be considered in patients with chronic bronchitis.
• The use of long-term macrolides is possible in a particular profile subset of patients who have frequent exacerbations with bronchiectasis, bronchial colonization, and frequent bacterial infections.