Pharmacologic Management of Chronic Obstructive Pulmonary Disease
Publication Date: April 1, 2020
Last Updated: May 27, 2022
Key Points
Key Points
- The Global Initiative for Chronic Obstructive Lung Disease 2019 report defines chronic obstructive pulmonary disease (COPD) as a “common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases.”
- Pharmacologic treatment for COPD aims to improve quality of life (QOL) and control symptoms while reducing the frequency of exacerbations.
Table 1. Implications of Strong and Conditional Recommendations
| Strong Recommendation (“The ATS recommends...”) | Conditional Recommendation (“The ATS suggests...”) | |
|---|---|---|
| Patients | The overwhelming majority of individuals in this situation would want the recommended course of action, and only a small minority would not. (It is the right course of action for >95% of patients.) | Most individuals in this situation would want the suggested course of action, but many would not. (It is the right course of action for >50% of patients.) |
| Clinicians | The overwhelming majority of individuals should receive the recommended course of action. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences. (It is reasonable to recommend it strongly to patients and caregivers.) | Different choices will be appropriate for different patients, and the clinician must help each patient arrive at a management decision consistent with her or his values and preferences. Decision aids may be useful to help individuals make decisions consistent with their values and preferences. Clinicians should expect to spend more time with patients when working toward a decision. (Slow down, think about it, discuss it with the patient.) |
| Policy makers | The recommendation can be adopted as policy in most situations, including for use as a performance indicator. (The recommended course of action may be an appropriate performance measure.) | Policy making will require substantial debates and involvement of many stakeholders. Policies are also more likely to vary between regions. Performance indicators would have to focus on the fact that adequate deliberation about the management options has taken place. (The recommended course of action is not appropriate for a performance measure.) |
Treatment
Treatment
In patients with COPD who complain of dyspnea or exercise intolerance, the ATS2 recommends long-acting β-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy. ( S )
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In patients with COPD who complain of dyspnea or exercise intolerance despite dual therapy with LABA/LAMA, the ATS suggests the use of triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA over dual therapy with LABA/LAMA in those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization. ( C )
621
In patients with COPD who are receiving triple therapy (ICS/LABA/LAMA), the ATS suggests that the ICS can be withdrawn if the patient has had no exacerbations in the past year. ( C )
621
The ATS does not make a recommendation for or against ICS as an additive therapy to long-acting bronchodilators in patients with COPD and blood eosinophilia, except for those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization, for whom we suggest ICS as an additive therapy. ( C )
621
In patients with COPD and a history of severe and frequent exacerbations despite otherwise optimal therapy, the ATS advises against the use of maintenance oral corticosteroid therapy. ( C )
621
In individuals with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy, the ATS suggests that opioid-based therapy be considered for dyspnea management, within a personalized shared decision-making approach. ( C )
621
Recommendation Grading
Abbreviations
- ATS: American Thoracic Society
- COPD: Chronic Obstructive Pulmonary Disease
- ICS: Inhaled Corticosteroid(s)
- LABA: Long Acting β 2 Agonist
- LAMA: Long-acting Muscarinic Antagonist
- QOL: Quality Of Life
Source Citation
Nici, L., Mammen, M., Charbek, E., et al. Pharmacologic Management of COPD: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med, 2020;201(9), pp.e56–e69.
Disclaimer
This resource is for informational purposes only, intended as a quick-reference tool based on the cited source guideline(s), and should not be used as a substitute for the independent professional judgment of healthcare providers. Practice guidelines are unable to account for every individual variation among patients or take the place of clinician judgment, and the ultimate decision concerning the propriety of any course of conduct must be made by healthcare providers after consideration of each individual patient situation. Guideline Central does not endorse any specific guideline(s) or guideline recommendations and has not independently verified the accuracy hereof. Any use of this resource or any other Guideline Central resources is strictly voluntary.