Canadian Thoracic Society Clinical Practice Guideline on pharmacotherapy in patients with COPD – 2019 update of evidence

Abstract

In this guideline update, we highlight important and new findings related to pharmacological therapy of chronic obstructive pulmonary disease (COPD) that should change clinical practice and improve disease management. We present updated evidence, recommendations and expert clin- ical remarks on maintenance pharmacotherapy in patients with stable COPD. The diagnosis and nonpharmacological therapy of COPD are out-of-scope for this update. In patients with COPD who have persistent shortness of breath, exercise intolerance and/or poor health status despite using inhaled LAMA or LABA monotherapy, we recommend augmenting treatment to LAMA/LABA dual therapy. In patients with high-risk exacerbations, LAMA/LABA is the preferred choice to ICS/LABA except in patients with previous exacerbations who have higher per- ipheral eosinophilia. There is no role for ICS monotherapy; when indicated, ICS should only be used in combination with bronchodilators. Treatment “step up” in COPD is proposed as a practical construct supported by evidence that inhaled combined therapy is superior to monotherapy and triple therapy to dual therapy in certain patient populations. Because the superiority of inhaled tri- ple or dual bronchodilator therapy may not be achieved in every patient, “step down” may be considered for some patients (not at high risk for future exacerbations), but should be done with close medical supervision, as the risk of clinical deterioration is real and continues to exist. The decision of changing a therapy should always occur after a complete evaluation of the patient and the potential benefit to a change in therapy; as well as an assessment of any adverse effects of the therapy, and with a review of patient adherence, inhaler technique and patient preferences. Pharmacological therapy plays a foundational role in therapy, but it should never be the sole treatment in managing COPD patients. Clinicians should always combine and optimize pharmaco- logical and nonpharmacological therapies with the dual goals of reducing symptoms and prevent- ing acute exacerbations of COPD (AECOPD).