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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 Additional interventions may include LAMA-LABA-ICS, 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: Best option for most patients, particularly if blood eosinophils <300/microL LABA-ICS: If LAMA contraindicated and 1 exacerbation in past year with blood eosinophils ≥300/microL or ≥2 exacerbations or 1 hospitalization in past year with blood eosinophils ≥100/microL
LAMA-LABA	LAMA-LABA-ICS (blood eosinophil count ≥100/microL increases likelihood of ICS benefit) OR Continue LAMA-LABA, if blood eosinophils <100 (indicates lesser likelihood that addition of ICS will be beneficial) Add roflumilast^¥ OR Add azithromycin^‡
LABA-ICS	LAMA-LABA-ICS if prior indication for ICS (eg, 1 exacerbation in past year and blood eosinophils ≥300/microL or ≥2 exacerbations or 1 hospitalization in past year and blood eosinophils ≥100/microL) 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 effect to 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) and frequency of exacerbations. 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 for information on nonpharmacologic therapy.

¶ mMRC dyspnea scale: Refer to UpToDate content; 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.

◊ 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.

§ Combination of LAMA-ICS is unstudied. For patients on this regimen who have persistent exacerbations and/or dyspnea, a change to LAMA-LABA-ICS would be a reasonable next step.

¥ Roflumilast is used for patients with chronic bronchitis and FEV₁ <50% predicted, particularly if 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. 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 (2019 Report). Available at: www.goldcopd.org (Accessed on August 12, 2019).

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