Initiating or Continuing Long-Acting Bronchodilators in COPD

Introduction to COPD Management

The American Thoracic Society recommends initiating long-acting bronchodilators in all patients with COPD Group B (high symptoms, low risk of exacerbations) or higher, with LABA/LAMA combination being the preferred initial therapy for patients in Group D (high symptoms, high risk of exacerbations) due to its superior efficacy in preventing exacerbations and improving patient-reported outcomes compared to monotherapies or LABA/ICS combinations 1, 2.

For patients in Group A (low symptoms, low risk of exacerbations), offer a short-acting or long-acting bronchodilator based on patient preference, and continue the bronchodilator only if symptomatic benefit is observed 1, 2.
For patients in Group B (high symptoms, low risk of exacerbations), initiate a long-acting bronchodilator (LABA or LAMA) as initial therapy, with the choice depending on individual response 1, 2, 3.
For patients in Group D (high symptoms, high risk of exacerbations), the combination LABA/LAMA is recommended as initial therapy because it shows superior results in preventing exacerbations and improving patient-reported outcomes compared to LABA/ICS or monotherapies 1, 2, 3, 5.

For patients on LABA/LAMA who develop additional exacerbations, consider escalating to LABA/LAMA/ICS (triple therapy), especially if eosinophils ≥300 cells/μL or history of asthma-COPD overlap 1, 2.
For patients in LABA/LAMA/ICS with persistent exacerbations, consider adding roflumilast if FEV1 <50% predicted and chronic bronchitis, or adding a macrolide in ex-smokers with exacerbations despite appropriate therapy 1, 2, 6.

For patients with asthma-COPD overlap, LABA/ICS should be the first choice for initial therapy, considering the risk of severe exacerbations and asthma-related mortality 1, 7.
The use of LABA/LAMA as initial therapy is not recommended in asthma-COPD overlap due to the increased risk of severe exacerbations and asthma-related mortality 7.

The combination LABA/LAMA reduces the risk of pneumonia compared to LABA/ICS, with an odds ratio of 1.69 (95% CI 1.20-2.44) in high-risk populations 1, 2.
Long-term monotherapy with ICS is not recommended (Evidence A), and the use of oral corticosteroids for long-term therapy is also not recommended (Evidence A) 1, 2.