Chronic obstructive pulmonary disease (COPD) — maintenance

Use at a glance

• Smoking cessation + vaccines are foundational

Treatment options

• Long-acting bronchodilator = core therapy
• Symptoms: LABA/LAMA; often dual therapy

Choosing treatment

• Exacerbations + eosinophils → consider ICS
• Pulmonary rehab improves function

Treatment selection

• Triple therapy if exacerbations persist
• Roflumilast/azithro for selected frequent exacerbators

Key points

• All COPD: smoking cessation (pharmacotherapy helps), pulmonary rehab, inhaler technique check
• Vaccinate: influenza, pneumococcal (↓ exacerbations/LRTIs), plus COVID-19, RSV, Tdap, zoster
• Occasional dyspnea: short-acting bronchodilator PRN; mild symptoms: LAMA or LABA monotherapy
• Long-acting bronchodilators (LAMA/LABA) maintenance: ↓ symptoms, exacerbations; ↑ lung function
• LAMA+LABA: initial for moderate-severe symptoms or exacerbation history, or failed monotherapy
• Triple ICS/LAMA/LABA if uncontrolled on dual or eosinophils ≥300/mcL; ensifentrine (Ohtuvayre) add-on alternative
• Exacerbations despite LABA/LAMA/ICS: roflumilast (Daliresp) if chronic bronchitis; azithromycin if non-current smoker

Nonpharmacologic therapies

• Smoking cessation
• Vaccination
• Pulmonary rehabilitation
• Inhaler technique assessment
• Long-term oxygen therapy

Pearls

• Keep a SABA on hand; not for regular maintenance
• Eosinophils <100: weak ICS response, more pneumonia
• Withdrawing ICS risky when eosinophils ≥300
• Single-inhaler combinations preferred for dual or triple therapy
• Triple therapy lowers mortality vs LAMA/LABA but adds pneumonia

Self-check

• What is foundational in COPD maintenance?
  Smoking cessation and vaccines.
• When should ICS be considered in COPD maintenance?
  With exacerbations plus eosinophilia.

Drugs used for this (24)

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