COPD includes emphysema and chronic bronchitis. Common symptoms of COPD include coughing spells, wheezing, chest pain and shortness of breath. Long-acting muscarinic receptor antagonists (LAMAs) block the bronchoconstriction effect of acetylcholine. This prevents acetylcholine from causing the muscles surrounding the lungs’ airways to constrict, reducing the symptoms of COPD. For patients who have 0-1 moderate exacerbation (not leading to hospital admission) a long-acting bronchodilator (long-acting beta-agonist [LABA] or LAMA is recommended as per the modified medical research council dyspnoea questionnaire (mMRC) with a result of two or more, and COPD assessment test (CAT) result of 10 or more.
For patients who have two or more moderate exacerbations or one or more leading to hospitalisation, initial therapy should consist of a single long-acting bronchodilator. GOLD recommends starting therapy with a LAMA in this group.
For patients who have two or more moderate exacerbations or one or more leading to hospitalisation, with mMRC of two or more, and CAT of 10 or more, therapy can be started with a LAMA as it has effects on both breathlessness and exacerbations. For patients with more severe symptoms (order of magnitude of CAT 20 or greater), especially driven by greater dyspnoea and/or exercise limitation, LABA/LAMA may be chosen as initial treatment.
In some patients, initial therapy with LABA/inhaled corticosteroid (ICS) may be the first choice. This treatment has the greatest likelihood of reducing exacerbations in patients with blood eosinophil counts of 300 cells per microlitre or greater. LABA/ICS may also be first choice in COPD patients with a history of asthma.
Dyspnoea
For patients with persistent breathlessness or exercise limitation on LABA/ICS treatment, LAMA can be added to escalate to triple therapy.
Exacerbations
For patients with persistent exacerbations on long-acting bronchodilator monotherapy, escalation to either LABA/LAMA or LABA/ICS is recommended. LABA/ICS may be preferred for patients with a history or findings suggestive of asthma. For patients with one exacerbation per year, a peripheral blood level of 300 eosinophils per microlitre or greater identifies patients more likely to respond to LABA/ICS treatment.
For patients with two or more moderate exacerbations per year or at least one severe exacerbation requiring hospitalisation in the prior year, LABA/ICS treatment can be considered at blood eosinophil counts of 100 cells per microlitre or greater, as ICS effects are more pronounced in patients with greater exacerbation frequency and/or severity.
In patients who develop further exacerbations on LABA/LAMA therapy, blood eosinophil counts of less than 100 cells per microlitre can be used to predict a low likelihood of a beneficial ICS response. GOLD suggests escalation to LABA/LAMA/ICS. In patients who develop further exacerbations on LABA/ICS therapy, GOLD recommends escalation to triple therapy by adding a LAMA. Alternatively, treatment can be switched to LABA/LAMA if there has been a lack of response to ICS treatment, or if ICS side effects warrant discontinuation.
References available on request.
