COPD

Maria G. Tanzi, PharmD

The American Thoracic Society (ATS) has released a clinical practice guideline on the pharmacologic management of chronic obstructive pulmonary disease (COPD). This guidance, in conjunction with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, is useful in helping pharmacists manage patients with COPD. 

“Both the ATS and GOLD guidelines are evidence based, but the ATS guidelines are much more concise,” Suzanne G. Bollmeier, PharmD, FCCP, BCPS, AE-C, professor of pharmacy practice at the St. Louis College of Pharmacy, told Pharmacy Today. “The ATS guidance addresses six specific questions related to the management of COPD patients in certain clinical situations, and practicing pharmacists may find the ATS document useful if already familiar with the GOLD guidelines.”  

GOLD vs. ATS guidance 

“The GOLD COPD guidelines are regularly used by health care providers as they provide current recommendations based on the most recent published primary literature,” Bollmeier said.

These guidelines, which are the standard when managing patients with COPD, include staging patients based on both their pulmonary function and symptoms (CAT or MMRC scores) and history of exacerbations (A, B, C, D risk stratification). The GOLD guidelines give evidence-based recommendations for both initial and follow-up therapy (dyspnea or exacerbation pathways).

In comparison, the ATS guidance discusses six scenarios that focus on recommendations for the appropriate use of long-acting beta-agonists (LABA), long-acting muscarinic antagonists (LAMA), inhaled corticosteroids (ICS), oral steroids, and opioid-based regimens.

Counseling patients with COPD   

Pharmacists should counsel patients with COPD  on the importance of medication adherence and proper inhalation technique. Some strategies to improve adherence may include using once to twice daily therapy as the goal and synchronizing doses if patients are using multiple inhalers. For current smokers, smoking cessation counseling is critical, and all patients who smoke should be encouraged to try to quit. 

In addition, pharmacists should educate patients on how to recognize and self-manage a COPD exacerbation. Discuss the importance of staying up to date with recommended vaccinations and performing some type of daily physical activity as tolerated. Training on how to cope with breathlessness, stress, anxiety, depression, and fatigue is also helpful for this patient population.

ATS recommendations for the pharmacologic treatment of COPD

Question 1: In patients with COPD who complain of dyspnea or exercise intolerance, is LABA/LAMA combination therapy more effective than and as safe as LABA or LAMA monotherapy?

LABA/LAMA is recommended over LABA or LAMA monotherapy.

Question 2: In patients with COPD who complain of dyspnea or exercise intolerance despite the use of dual therapy with LABA/LAMA, is triple therapy with ICS/LABA/LAMA more effective than and as safe as dual therapy with LABA/LAMA. 

Triple therapy is recommended over dual therapy for patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization.

Question 3: In patients with COPD receiving triple therapy (ICS/LABA/LAMA), should the ICS be withdrawn? 

The ICS can be withdrawn in those who have had no exacerbations in the past year.

Question 4: In patients with COPD and blood eosinophilia, should treatment include an ICS in addition to a long-acting bronchodilator?

No general recommendation is made for or against the addition of an ICS, but the addition of ICS is recommended for patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization.

Question 5: In patients with COPD who have a history of severe and frequent exacerbations despite otherwise optimal therapy, is maintenance oral steroid therapy more effective than and as safe as no maintenance oral steroid therapy?

The use of maintenance oral steroids is not recommended.

Question 6: In patients with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy, is opioid-based therapy more effective than and as safe as no additional therapy?

Opioid-based therapy may be considered for dyspnea management with a personalized shared decision-making approach.