Follow-up management of COPD*

No exacerbations and no dyspnea/low COPD impact (ie, mMRC 0 to 1 or CAT <10)^¶
Current therapy	Actions
SABA or SABA-SAMA as needed	Continue current therapy
LAMA, LABA, or LAMA-LABA	Continue current therapy
LABA-ICS or LABA-LAMA-ICS	Taper or discontinue ICS dose to reduce adverse effects of ICS^Δ
Persistent dyspnea or high COPD impact (ie, mMRC ≥2 or CAT ≥10)^¶ with no exacerbations
Current therapy	Actions
SABA or SABA-SAMA as needed	Add LAMA or LABA
LAMA or LABA monotherapy	Change to LAMA-LABA
LABA-ICS	LAMA-LABA-ICS LAMA-LABA if lack of response to ICS or adverse effects from ICS
LAMA-LABA	Substitute alternate delivery system or different LAMA-LABA agents Trial of LAMA-LABA-ICS, in patients with blood eosinophils ≥100 cells/microL^◊ Additional interventions may include low-dose theophylline, repeat pulmonary rehabilitation, and nonpharmacologic therapies^§
LAMA-LABA-ICS	Continue LAMA-LABA-ICS Additional interventions may include low-dose theophylline, repeat pulmonary rehabilitation, and nonpharmacologic therapies for COPD^§ Stop ICS, if initial indication unclear, lack of response, or adverse effect to ICS^Δ
1 or more exacerbations in past year +/– persistent dyspnea or high COPD impact (ie, mMRC ≥2 or CAT ≥10)^¶
Current therapy^§	Actions
SABA or SABA-SAMA as needed	Add LAMA
LAMA or LABA monotherapy	LAMA-LABA, if blood eosinophil count <300/microL^◊ or LAMA-LABA-ICS, if blood eosinophil count ≥300/microL^◊ or hospitalization for COPD exacerbation or LABA-ICS, if blood eosinophil count ≥100/microL^◊ and LAMA contraindicated
LAMA-LABA	LAMA-LABA-ICS, if blood eosinophil count ≥100/microL^◊ or Continue LAMA-LABA, if blood eosinophil count <100/microL^¥ Add roflumilast^‡ or Add azithromycin^†
LABA-ICS	LAMA-LABA-ICS or LAMA-LABA if lack of response to ICS or adverse effects from ICS^Δ
LAMA-LABA-ICS	Continue LAMA-LABA-ICS Add roflumilast^‡ or Add azithromycin^† Stop ICS if initial indication unclear, lack of response, or adverse effects of ICS^Δ

COPD: chronic obstructive pulmonary disease; mMRC: modified Medical Research Council; CAT: COPD Assessment Test; SABA: short-acting beta-agonist; SAMA: short-acting muscarinic-antagonist; LAMA: long-acting muscarinic-antagonist; LABA: long-acting beta-agonist; ICS: inhaled corticosteroids (glucocorticoids); BMI: body mass index; SpO₂: pulse oxygen saturation; FEV₁: forced expiratory volume in one second.

* Adjustments to pharmacologic therapy for COPD are based on an assessment of dyspnea/exercise limitation (mMRC or CAT), frequency of exacerbations, and peripheral blood eosinophil counts. Follow-up visits are also an opportunity to assess and reinforce nonpharmacologic interventions for COPD, including: smoking cessation; inhaler technique and adherence to medications; administration of pneumococcal and seasonal influenza vaccinations; pulmonary rehabilitation; and nutrition counselling regarding healthy diet and normal BMI. All patients with COPD should have a rapid relief inhaler available, either a SABA or a SABA-SAMA (SABA preferred for patients using a LAMA). Refer to UpToDate content on the overview of management for stable COPD.

¶ mMRC dyspnea scale: https://www.pcrs-uk.org/mrc-dyspnoea-scale; CAT evaluates health impact of COPD: https://www.catestonline.org.

Δ If blood eosinophil count ≥300 cells/microL, patient is more likely to experience exacerbations after ICS withdrawal. Close patient monitoring is required if ICS are withdrawn.

◊ In patients with exacerbations and blood eosinophil count ≥300 cells/microL, the addition of ICS is likely to be of benefit. For patients with eosinophil counts ≥100 but <300 cells/microL, ICS may improve exacerbation rates and pulmonary function.

§ Nonpharmacologic measures (eg, oxygen therapy if SpO₂ ≤88%, pulmonary rehabilitation, bronchoscopic or surgical lung volume reduction, lung transplantation) can help reduce dyspnea and exacerbations. Contributing comorbidities should be evaluated and treated. Not all patients achieve control of dyspnea or exacerbations despite optimal available pharmacotherapy.

¥ For patients with a blood eosinophil count <100 cells/microL, there is a low likelihood that addition of ICS will be beneficial and higher risk of pneumonia after the addition of ICS.

‡ Roflumilast is used for patients with chronic bronchitis and FEV₁ <50% predicted, particularly if there has been at least 1 hospitalization for an exacerbation in the past year. Potential adverse effects may limit use.

† Azithromycin preventive therapy is more effective in patients who are not current smokers. However, it may lead to development of resistant organisms.

Adapted from: Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease (2023 Report). Available at: www.goldcopd.org (Accessed on December 13, 2022).

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Follow-up management of COPD*