Management of chronic obstructive pulmonary disease (COPD)

The following recommendations are based on the 2015 GOLD Chronic Obstructive Pulmonary Disease (COPD) guidelines with input from local respiratory specialists. The recommendations are intended to guide and rationalise initial treatment choices when managing patients with COPD.

The South Devon Medicines Optimisation team has developed local resources for use by primary care clinicians in south Devon managing patients with COPD which can be accessed here.

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.

Previous COPD management recommendations were based on NICE guidelines. GOLD recommendations differ from NICE in that treatment options are more closely aligned to patient phenotype but are not to be thought of as a step-wise approach. A combined assessment of patients' symptoms, degree of airflow obstruction, exacerbation risk, and comorbidities should be used to assign patients to one of four groups (A, B, C or D), in order to guide therapy.

The summary recommendations below are intended to act as a guide for initial patient management only; choice should be based on the individualised assessment of symptoms and exacerbation risk. If patient remains symptomatic following initial management options, consider referral for specialist advice regarding other possible treatments. Each treatment regimen needs to be patient-specific, and individualised.

COPD treatment with long acting bronchodilators, and inhaled corticosteroid or long-acting beta2 agonist combinations should be prescribed only following confirmed COPD diagnosis. Long-term treatment with inhaled corticosteroids is only recommended for patients with severe and very severe airflow limitation and for patients with frequent exacerbations that are not adequately controlled by long-acting bronchodilators. Long-term monotherapy with inhaled corticosteroids is not recommended in COPD because it is less effective than the combination of inhaled corticosteroids with long-acting beta2-agonists.

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.

Key: Metered dose inhaler = (MDI); Dry powder inhaler = (DPI)

Category A: few symptoms & low risk of exacerbations

Typically, patient exhibits:

  • FEV1 at least 50% of predicted
  • Not more than one exacerbation per year, without hospitalisation
  • COPD Assessment Test (CAT) score less than 10 or mMRC grade 0-1, MRC 1-2

Recommended inhaled treatment: SABA, or SAMA, or LAMA

Short-acting beta 2 agonist (SABA) monotherapy when required:

Salbutamol (MDI)

  • 100-200 micrograms, when required

OR

Short-acting muscarinic antagonist (SAMA) monotherapy when required:

Ipratropium (MDI)

  • 20 micrograms four times a day, when required

OR

Long-acting muscarinic antagonist (LAMA) monotherapy:

Spiriva® Respimat® (tiotropium solution for inhalation)

  • 5 micrograms once daily, or

Braltus® Zonda® (tiotropium DPI)

  • 10 micrograms inhaled daily, or

Seebri® Breezhaler® (glycopyrronium DPI)

  • 50 micrograms inhaled daily, or

Eklira® Genuair® (aclidinium DPI)

  • 375 micrograms twice a day

See sections: 3.1.1 Adrenoceptor agonists and 3.1.2 Antimuscarinic bronchodilators

Category B: more significant symptoms, low risk of exacerbations

Typically, patient exhibits:

  • FEV1 at least 50% of predicted
  • No more than one exacerbation per year, without hospitalisation
  • CAT score 10 or above or mMRC grade 2 or above, MRC grade 3 or above

Recommended inhaled treatment: LABA plus LAMA, or LAMA or LABA monotherapy

Long-acting beta 2 agonist (LABA) plus long-acting muscarinic antagonist (LAMA):

Ultibro® Breezhaler® (indacaterol/glycopyrronium DPI)

  • 1 capsule inhaled daily, or

Duaklir® Genuair® (formoterol/aclidinium DPI)

  • 1 puff twice a day

OR

Monotherapy with long-acting muscarinic antagonist (LAMA):

Spiriva® Respimat® (tiotropium solution for inhalation)

  • 5 micrograms once daily, or

Braltus® Zonda® (tiotropium DPI)

  • 10 micrograms inhaled daily, or

Seebri® Breezhaler® (glycopyrronium DPI)

  • 50 micrograms inhaled daily, or

Eklira® Genuair® (aclidinium DPI)

  • 375 micrograms twice a day

OR

Monotherapy with long-acting beta 2 agonist monotherapy (LABA):

Formoterol (MDI or DPI)

  • 12 micrograms twice a day, or

Indacaterol (DPI)

  • 150-300 micrograms once daily, or

Salmeterol (MDI or DPI)

  • 50 micrograms twice daily

See sections: 3.1.1 Adrenoceptor agonists and 3.1.2 Antimuscarinic bronchodilators

Category C: few symptoms but high risk of exacerbations

Typically, patient exhibits:

  • FEV1 less than 50% of predicted
  • At least 2 COPD exacerbations per year, including one or more leading to hospital admission
  • CAT score less than 10 or mMRC grade 0-1, MRC 1-2

Recommended inhaled treatment: LABA plus LAMA, or ICS plus LABA, or LAMA monotherapy

Long-acting beta 2 agonist (LABA) plus long-acting muscarinic antagonist (LAMA):

Ultibro® Breezhaler® (indacaterol/glycopyrronium DPI)

  • 1 capsule inhaled daily, or

Duaklir® Genuair® (formoterol/aclidinium DPI)

  • 1 puff twice a day

OR

Inhaled corticosteroid plus long-acting beta2 agonist:

Fostair® 100/6 (beclomethasone/formoterol MDI or DPI)

  • 2 puffs twice a day, or

Relvar® Ellipta® 92/22 (fluticasone furoate/vilanterol DPI)

  • 1 puff daily, or

Duoresp® Spiromax® 320/9 (budesonide/formoterol DPI)

  • 1 puff twice a day, or

Symbicort® 400/12 (budesonide/formoterol DPI)

  • 1 puff twice a day

OR

Long-acting muscarinic antagonist (LAMA) monotherapy:

Spiriva® Respimat® (tiotropium solution for inhalation)

  • 5 micrograms once daily, or

Braltus® Zonda® (tiotropium DPI)

  • 10 micrograms inhaled daily, or

Seebri® Breezhaler® (glycopyrronium DPI)

  • 50 micrograms inhaled daily, or

Eklira® Genuair® (aclidinium DPI)

  • 375 micrograms twice a day

See sections: 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, patient exhibits:

  • FEV1 less than 50% of predicted
  • At least 2 COPD exacerbations per year, including one or more leading to hospital admission
  • CAT score 10 or above or mMRC grade 2 or above, MRC grade 3 or above

Recommended inhaled treatment: ICS plus LABA and LAMA, or LABA plus LAMA

Triple combination inhaler (ICS + LABA + LAMA)

Trimbow® (beclometasone dipropionate, formoterol fumarate dihydrate and glycopyrronium MDI)

  • 87 micrograms / 5 micrograms / 9 micrograms per inhalation
  • Two puffs twice a day, or

Trelegy® Ellipta® (fluticasone furoate, vilanterol trifenatate and umeclidinium bromide DPI)

  • 92 micrograms / 22 micrograms / 55 micrograms per inhalation
  • one inhalation once daily

OR

Inhaled corticosteroid plus long-acting beta2 agonist and long-acting muscarinic antagonist:

Fostair® 100/6 (beclomethasone/formoterol MDI or DPI)

  • 2 puffs twice a day, or

Relvar® Ellipta® 92/22 (fluticasone furoate/vilanterol DPI)

  • 1 puff daily, or

Duoresp® Spiromax® 320/9 (budesonide/formoterol DPI)

  • 1 puff twice a day, or

Symbicort® 400/12 (budesonide/formoterol DPI)

  • 1 puff twice a day

AND

Long-acting muscarinic antagonist (LAMA):

Spiriva® Respimat® (tiotropium solution for inhalation)

  • 5 micrograms once daily, or

Braltus® Zonda® (tiotropium DPI)

  • 10 micrograms inhaled daily, or

Seebri® Breezhaler® (glycopyrronium DPI)

  • 50 micrograms inhaled daily, or

Eklira® Genuair® (aclidinium DPI)

  • 375 micrograms twice a day

Notes

  1. The cost/QALY for triple therapy in COPD (i.e. ICS plus LAMA plus LABA) is reported as being between £7,000 and £187,000, the upper limit of which is well above the NICE threshold of £20,000-£30,000 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 at least annually.

OR

Long-acting beta 2 agonist (LABA) plus long-acting muscarinic antagonist (LAMA):

Ultibro® Breezhaler® (indacaterol/glycopyrronium DPI)

  • 1 capsule inhaled daily, or

Duaklir® Genuair® (formoterol/aclidinium DPI)

  • 1 puff twice a day

See sections: 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 6.6 Drugs affecting 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: 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 nebuliser for people with distressing or disabling breathlessness despite maximum therapy with inhalers, and continued only if there is an improvement in symptoms, daily living activities, exercise capacity or lung function. 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. Self-management education and the issuing of a written action plan have been shown to improve outcomes for COPD.

There are a number of COPD self-management plans available, it is important to consider individual patient circumstances to ensure the plan given is one the patient will be able to use effectively.

Some examples of self-management plans 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.

Western Locality

Rescue Pack Leaflet: Amoxicillin or Doxycycline

GP information

Pharmacy information

South Devon and Torbay

Rescue Pack Leaflet

GP information

Pharmacy information

Local COPD services

COPD care should be delivered by a multidisciplinary team. Details of the services for each area are listed below:

Western Locality

Community respiratory service, based at:

  • Cumberland Centre, Damerel Close, Plymouth, PL1 4JZ.
  • Telephone: 01752 434342
  • Fax: 01752 314627
  • Hours of work: 8.30 am to 5.00pm Monday to Sunday.
  • Telephone advice available Bank Holidays (please note no physiotherapy available weekends).
  • Answer phone message service available out of hours
  • Service Manager:

Pulmonary rehabilitation

This is a programme of education and exercise intended to improve self-management and reduce dyspnoea. NICE recommends that pulmonary rehabilitation should be offered to all patients who consider themselves to be functionally disabled by COPD with an MRC score of 3 or more.

Western Locality
Cornwall patients
  • Cornwall Partnership NHS Trust (01326) 434705
  • Referral information can be found here
South Devon and Torbay

Referrals can be made to Sue Jones, COPD Nurse Specialist

 

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