Management of chronic obstructive pulmonary disease (COPD)

The following recommendations are adapted from the GOLD Chronic obstructive pulmonary disease (COPD) (2017 update) with input from local specialists, which is intended to guide and rationalise initial treatment choice when managing patients with COPD.

Patients already established on different inhaler therapies and remaining stable should continue their regular treatment, unless part of a dedicated concordant COPD review indicates a need to review and optimise therapy. Therapy should be reviewed annually and following an exacerbation.

GOLD recommendations differ from NICE in that treatment options are more closely aligned to patient phenotype.

FEV1 is no longer included in the ABCD grid as a factor to consider when choosing pharmacological therapy as it is not as good a predictor of response as the level of symptoms and the history of exacerbations. Local ABCD grid.

A combined assessment of patients' symptoms, exacerbation risk, and comorbidities should be used to assign patients to one of four groups: A, B, C or D. Each treatment regimen needs to be patient-specific, and individualised. The summary recommendations below have been proposed by local specialists, and are intended to act as a guide for initial patient management only. The products are listed in preferred order of choice within each category.

All COPD patents still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity.

Pulmonary rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD (usually Modified British Medical Research Council (mMRC) dyspnoea scale grade 3 and above), including those who have had a recent hospitalisation for an acute exacerbation. Pulmonary rehabilitation is not suitable for patients who are unable to walk, have unstable angina or who have had a recent myocardial infarction.

COPD treatment with long acting bronchodilators and inhaled corticosteroid/ long-acting beta2 agonist (ICS/LABA) combinations should be prescribed only following confirmed COPD diagnosis.

When new medication is added the patient should be re-assessed at 6 – 12 weeks to review effectiveness and reduction in symptoms. If there is no improvement the medication should be stopped and an alternative tried.

Category A: few symptoms & low risk of exacerbations

Typically, patients exhibit:

  • Low exacerbation risk (not more than 1 exacerbation, without hospitalisation, per year) and:
  • Fewer symptoms (COPD Assessment Test (CAT) score less than 10 or mMRC grade 0-1, MRC 1-2)

Short-acting beta2 agonist (SABA) taken when required, or

Short-acting muscarinic antagonist (SAMA) taken when required, or

Regular long-acting muscarinic antagonist (LAMA) monotherapy

See section: 3.1.1 Adrenoceptor agonists and 3.1.2 Antimuscarinic bronchodilators

Category B: more significant symptoms, low risk of exacerbations

Typically, patients exhibit:

  • Low exacerbation risk (no more than one exacerbation per year without hospitalisation), and
  • More symptoms (CAT score 10 or above or mMRC grade 2 or above, MRC grade 3 or above)

LAMA monotherapy, or

LABA monotherapy, or

LAMA plus LABA

See section: 3.1.1 Adrenoceptor agonists and 3.1.2 Antimuscarinic bronchodilators

Category C: few symptoms but high risk of exacerbations

Typically, patient has:

  • High exacerbation risk (at least 2 COPD exacerbations per year, including one hospital admission or more)
  • Fewer symptoms (CAT score less than 10 or mMRC grade 0-1, MRC 1-2)

LAMA monotherapy, or

LAMA plus LABA, or

ICS / LABA combination inhaler

See section: 3.1.1 Adrenoceptor agonists, 3.1.2 Antimuscarinic bronchodilators and 3.1.4 Combination inhalers

Category D: many symptoms with high risk of exacerbations

Typically, patients has

  • High exacerbation risk (at least 2 COPD exacerbations per year, including one hospital admission or more)
  • More symptoms (CAT score 10 or above or mMRC grade 2 or above, MRC grade 3 or above)

LAMA monotherapy, or

LAMA plus LABA, or

LAMA plus ICS / LABA combination inhaler

Notes

  1. The cost/QALY for triple therapy in COPD (i.e. ICS plus LAMA plus LABA) is reported as being between £35,000 and £187,000 which is well above the NICE threshold of £21,000 per QALY for a treatment to be regarded as cost effective.
  2. Add a third agent on a trial basis; if additional benefit is not seen, consider if continuation is warranted.
  3. Patients should be reviewed annually at least.
  4. If patient remains symptomatic consider referral for specialist advice regarding further treatment options.

See section: 3.1.1 Adrenoceptor agonists, 3.1.2 Antimuscarinic bronchodilators and 3.1.4 Combination inhalers

Other treatments

Smoking cessation: Stopping smoking is one of the most valuable interventions that can be made and all patients should be encouraged to stop at every opportunity and offered smoking cessation support. See Smoking cessation section for formulary choices.

Oral steroids: The use of oral corticosteroids as maintenance treatment is not generally recommended. In a few patients with advanced COPD maintenance treatment with oral steroids may be needed if they cannot be withdrawn after an exacerbation. In these cases the dose should be kept as low as possible and consideration given to osteoporosis prophylaxis in line with RCP guidelines (see 6.4 Disorders of bone metabolism).

Mucolytic therapy can be considered for patients with a chronic productive cough and continued only if there is symptomatic improvement following a 4-week trial (see 3.7 Mucolytics).

Pneumonia: Physicians should remain vigilant for pneumonia and other infections of the lower respiratory tract (i.e. bronchitis) in patients with COPD who are treated with inhaled products that contain steroids (see Lower respiratory tract infections)

Pulmonary rehabilitation is recommended for patients who consider themselves functionally disabled by COPD (usually MRC grade 3 and above). Pulmonary rehabilitation is not suitable for patients who are unable to walk, have unstable angina or who have had a recent myocardial infarction.

Vaccinations: Pneumococcal vaccination and an annual influenza vaccination should be offered to all patients with COPD

Nebulisers: Consider a nebulised therapy for people with distressing or disabling breathlessness despite maximum therapy with inhalers. Continue only if symptoms, daily living activities, exercise capacity or lung function improves. For more information see Nebulised therapy

Palliative Care: Opiates can be used for the palliation of breathlessness in patients with end stage COPD unresponsive to other medical therapy in consultation with a specialist. Use benzodiazepines, tricyclic antidepressants, major tranquilisers and oxygen where appropriate. Involve multidisciplinary palliative care teams and hospices.

Steroids and pneumonia

Physicians should remain vigilant for the development of pneumonia and other infections of the lower respiratory tract (i.e. bronchitis) in patients with COPD who are treated with inhaled drugs that contain steroids because the clinical features of such infections and exacerbations frequently overlap. Any patient with severe COPD who has had pneumonia during treatment with inhaled steroids should have their treatment reconsidered.

Managing exacerbations

Initial management:

  • Increased frequency of bronchodilator use. Consider nebulised therapy.
  • Oral antibiotics should be used only if there is purulent sputum (see 5. Infections- Lower Respiratory Tract Infections).
  • Use prednisolone 30mg daily for 7-14 days in patients with a significant increase in breathlessness and in all patients admitted to hospital unless contra-indicated.
  • Patients at risk of having an exacerbation of COPD should be given a course of antibiotic and corticosteroid tablets to keep at home for use as part of a self-management plan (see below)

COPD self–management plans

Patients at risk of an exacerbation of COPD should be given self-management advice that encourages them to respond promptly to the symptoms of an exacerbation. Local COPD self-management plans are as follows:

Example of self-management plan available:

COPD Rescue Packs

Appropriate provision of a standby supply of antibiotics and corticosteroid COPD Rescue Pack should be given to be kept at home for use as part of a self-management strategy.

Antibiotics should be prescribed in line with the local Primary Care Antimicrobial Guidelines

Important: Please note these information leaflets are only relevant to prescriptions for standby supply of antibiotics and corticosteroid prescribed as described here, this is due to the specific nature of information contained regarding drugs and their doses.

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