Version July 2025
CAT: COPD assessment test; COPD: chronic obstructive pulmonary disease; ICS: inhaled corticosteroids (glucocorticoids); LABA: long-acting beta-agonist; LAMA: long-acting muscarinic-antagonist; mMRC: modified medical research council; SABA: short-acting beta-agonist; SAMA: short-acting muscarinic-antagonist; SpO2: peripheral oxygen saturation.
* mMRC dyspnea scale: https://www.pcrs-uk.org/mrc-dyspnoea-scale; CAT evaluates health impact of COPD: https://www.catestonline.org.
¶ Ensifentrine may reasonably be substituted for LAMA or LABA therapy if one of these agents cannot be used due to adverse effects or other contraindications.
Δ For patients who are on LABA-ICS therapy, switching to LAMA-LABA-ICS rather than LAMA-LABA is a reasonable option if there has been a beneficial effect from the ICS without adverse effects.
◊ In patients with dyspnea and blood eosinophil count ≥300 cells/microL, the addition of ICS is most likely to be of benefit. Patients with eosinophil counts <100 are less likely to experience improvements in dyspnea.
§ Ensifentrine has not been well studied as add-on therapy to both LAMA and LABA. Until further data are available, however, the distinct mechanism of action and favorable side-effect profile of this agent drive its preferred use in this setting.
¥ For those with persistent symptoms despite LAMA, LABA, and ensifentrine (+/– ICS), 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. Please refer to UpToDate content on management of refractory COPD for additional information.
