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
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
- 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
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|
|SABA||Salbutamol sulfate||Ventolin||Metered-dose inhaler
|SAMA||Ipratropium bromide||Atrovent||Metered-dose inhaler
|ICS/LABA||Budesonide/eformoterol fumarate dihydrate||Symbicort||Rapihaler
|ICS/LABA||Fluticasone propionate/salmeterol xinafoate||Seretide||Accuhaler
|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)
- Therapeutic Guidelines: Respiratory. Chronic obstructive pulmonary disease. 2013. [Online] (accessed 16 August 2014).
- Australian Lung Foundation. Stepwise management of stable COPD. 2014. [Onine] (accessed 28 August 2014).
- Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2013. [Online] (accessed 16 August 2014).
- Abramson M, Crockett AJ, Dabscheck E, et al. The COPDX Plan: Australian and New Zealand Guidelines for the management of chronic obstructive pulmonary disease 2014. Lung Foundation Australia. [Online] (accessed 28 August 2014).