Stepwise management of COPD

Management of stable COPD requires a stepwise approach.1

Non-pharmacological interventions such as smoking cessation, weight control, exercise and pulmonary rehabilitation are an important part of COPD management at every stage.

Pharmacological interventions typically involve starting treatment with a short-acting reliever (either a short-acting beta-2 receptor agonist [SABA] or a short-acting anticholinergic/muscarinic receptor antagonist [SAMA]) as needed for symptom relief, before adding maintenance therapy with one or more long-acting bronchodilators. 1

Long-acting bronchodilators include beta-2 agonists (LABAs) or anticholinergics/muscarinic antagonists (LAMAs).

Combination therapy with an inhaled corticosteroid (ICS) and a LABA is indicated for patients who remain symptomatic after treatment with long-acting bronchodilators (FEV1 ≤ 50% predicted and two or more exacerbations requiring treatment in the previous year).1, 2

There is some evidence to support triple therapy (LABA + LAMA + ICS) improving lung function and quality of life, but more studies are required.3, 4

Consider adding theophylline in patients with severe COPD for whom other treatments have failed to control symptoms adequately.1, 2, 4

Combining bronchodilators of different classes may improve efficacy and decrease risk of side effects compared with increasing the dose of a single bronchodilator.3

However, there is limited evidence on the best choice of combinations of medicines for COPD management.1 Regimens are guided by the severity of symptoms, risk of exacerbations and the patient’s response.3

Bronchodilator combinations to avoid

While therapy combinations need to be patient specific, some classes of medicines should not be used together.4 Key points to remember when adding therapies are:2

  • do not double-up inhalers containing an anticholinergic (SAMA or LAMA or LABA/LAMA fixed-dose combination [FDC])
  • do not double up inhalers containing a LABA (LABA or LABA/ ICS or LABA/LAMA FDC)
  • a SABA may be used alongside all inhalers for symptom relief.

Applying these guidelines in stepwise management of COPD means certain medicines need to be discontinued before starting others. Check guidelines for recommendations about combination therapy before adding an inhaler.1, 2, 4

The Lung Foundation of Australia offers the Stepwise Management of Stable COPD resource,2 which includes a visual guide to addition of therapies.

Place of combination bronchodilators in management of COPD

FDC bronchodilators can simplify COPD treatment regimens by combining two separate medicines in a single device.1 Refer to guidelines for addition of therapies as stated above. This will include discontinuing the individual component therapies once the FDC medicine is started.

Currently available inhaled bronchodilators for COPD

Table 1 PBS-listed inhaled bronchodilators for the treatment of COPD*
Abbreviation Active ingredient Medicine brand name Inhaler type or brand name
Short-acting bronchodilators
SABA Salbutamol sulfate Ventolin Metered-dose inhaler
Rotahaler
Suitable nebuliser
Airomir Autohaler
Asmol Metered-dose inhaler
SABA Terbutaline sulfate Bricanyl Turbuhaler
SAMA Ipratropium bromide Atrovent Metered-dose inhaler
Suitable nebuliser
Aeron Suitable nebuliser
Ipratrin Suitable nebuliser
Long-acting bronchodilators
LABA Indacaterol maleate Onbrez Breezhaler
LAMA Tiotropium bromide Spiriva HandiHaler
LAMA Glycopyrronium bromide Seebri Breezhaler
LAMA Aclidinium bromide Bretaris Genuair
LAMA Umeclidinium bromide Incruse Ellipta
FDC bronchodilators
ICS/LABA Budesonide/eformoterol fumarate dihydrate Symbicort Rapihaler
Turbuhaler
ICS/LABA Fluticasone propionate/salmeterol xinafoate Seretide Accuhaler
Metered-dose inhaler
ICS/LABA Fluticasone furoate/vilanterol trifenatate Breo Ellipta
LABA/LAMA Vilanterol trifenatate/umeclidinium bromide Anoro Ellipta
LABA/LAMA Indacaterol maleate/glycopyrronium bromide Ultibro Breezhaler

* Australian Government Department of Health, Pharmaceutical Benefits Scheme. [Online] (accessed 8 September 2014)