This is our practice algorithm for COPD treatment:
Treat intermittent symptoms with a SABA.
If more severe, differentiate between low-risk and high-risk patients. Low-risk patients are those with:
- FEV1 >50%
- <2 exacerbations/yr
For low-risk patients:
- First-line treatment: LAMA
- If symptoms continue: LAMA/LABA combination
For high-risk patients:
- First-line treatment: LABA/ICS
- If symptoms continue: add LAMA
The algorithm also listed specific recommended inhalers, but do bear in mind that the brands will have been recommended largely on price grounds: in other words, it’ll mostly be because they’re currently cheaper than other brands rather than because they have any particular clinical difference from others. This therefore isn’t any kind of endorsement. The inhalers currently recommended are as follows:
- MDI: Tiotropium, as Spiriva Respimat 2.5 mg two puffs od.
- DPI: Aclidinium, as Eklira 322 mcg bd
- MDI: Spiolto via Respimat, once daily (contains Olodaterol + Tiotropium)
- DPI: Anoro (Umeclidinium/Vilanterol) via Ellipta once daily, or Duaklir (AclidiniumFormoterol) bd
- MDI: Fostair 100/6 two puffs bd (Beclometasone + Formoterol)
- DPI: Relvar 92/2200 (Fluticasone + Vilanterol) or Symbicort 400/12 one puff bd
If one of the above is combined with a LAMA for severe COPD, the guidelines suggest:
- Fostair – Spiriva, dose as above
- Relvar – Incruse 55 mg od
- Symbicort – Eklira, dose as above
I have no idea why. Oh, well, at least now this is all somewhere where I can find it all without having to cart the actual sheet around.