COPD inhaler strategy for patients with NO features suggesting asthma or steroid responsiveness

1) Offer SABA or SAMA as needed for symptom relief.

Then, if there are ongoing symptoms or exacerbations:

2) Offer LABA+LAMA

• This combination can improve both daily symptoms and reduce exacerbations.

Then, if there are still ongoing symptoms or exacerbations:

• Consider LABA+LAMA+ICS

The added value of inhaled corticosteroids will vary from person to person and may be marginal.

• They may improve symptoms or reduce exacerbations, but can also cause pneumonia and other side effects (see graphics and harms sections on the main page).
• It may be that the potential benefits do not outweigh the potential harms.
• It is important to be clear about the reason for prescribing and set up an appropriately timed review to think about whether to continue.

If the aim of treatment is to improve daily symptoms: >>>   trial the treatment for 3 months >>>   if no improvement, revert to LABA+LAMA

If the aim of treatment is to reduce exacerbations*, regardless of any day-to-day symptomatic benefit: >>>  potentially continue LABA+LAMA+ICS long term, considering at what point in the future a reduction in exacerbations will become apparent.

*NICE suggests a baseline level of exacerbations to consider starting ICS to be 1 severe (requiring hospitalisation) or 2 moderate (requiring steroids or antibiotics) exacerbations per year.

SABA, short-acting beta agonist; SAMA, short-acting muscarinic antagonist; LAMA, long-acting muscarinic antagonist; LABA, long-acting beta agonist; ICS: inhaled corticosteroid.