As a clinical pharmacist, implementing updated guidance will prompt inquiries into the optimal treatment approaches for COPD. There aren’t big changes, but it can be tough to assess if patients are on optimized therapy. Consider these rules of thumb...
✅ Ensure that all patients with COPD have a short-acting bronchodilator (albuterol, etc) PRN to relieve symptoms. And continue to evaluate symptoms and exacerbation history to guide selection of long-acting medications.
Low exacerbation risk. These are patients with up to 1 exacerbation in the past year, that did NOT require hospitalization. For mild symptoms (occasional breathlessness, etc), use a long-acting muscarinic antagonist (LAMA), such as umeclidinium, or long-acting beta-agonist (LABA), such as olodaterol (Spiolto). Keep in mind, LAMAs prevent exacerbations a bit better than LABAs. But choose a LABA/LAMA combo, such as vilanterol/umeclidinium (Anoro), for patients with more persistent or more severe symptoms.
High exacerbation risk. These are patients with 2 or more exacerbations in the past year, or any that required hospitalization. Prescribe a LABA/LAMA combo for most of these patients. But consider blood eosinophil levels to help identify patients more likely to benefit from adding an inhaled corticosteroid (ICS). For example, consider “triple therapy” with an ICS/LAMA/LABA, such as fluticasone/umeclidinium/vilanterol (Trelegy), as initial therapy for patients with eosinophils of 300 cells/µL or above, or those with exacerbations on a LABA/LAMA and eosinophils of at least 100 cells/µL.
Use a low ICS dose when possible, to limit pneumonia risk. Watch for patients using a LABA/ICS combo, such as salmeterol/fluticasone (Advair, etc), and evaluate if a switch to a LABA/LAMA or triple therapy is needed. Reserve roflumilast (Westabreath, Dalivent) or long-term azithromycin for patients with persistent exacerbations despite maximum therapy. But it’s still too soon to consider dupilumab (Dupixent) despite some evidence that it decreases exacerbations versus placebo in patients with COPD and high eosinophils. Finally, continue to assess adherence, reinforce proper inhaler technique and emphasize smoking or vaping cessation if needed. Help ensure patients are current with vaccines (flu, COVID-19, etc).
REFERENCES
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Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: 2024 Report. https://goldcopd.org/2024-gold-report/
Bhatt SP, Rabe KF, Hanania NA, et al. Dupilumab for COPD with Type 2 Inflammation Indicated by Eosinophil Counts. N Engl J Med. 2023;389(3):205-214. Available at: https://pubmed.ncbi.nlm.nih.gov/37272521