CTS position statement: Pharmacotherapy in patients with COPD—An update

Figures & data

Figure 1. Comprehensive Management of COPD. Integrated approach of care that includes COPD diagnosis with spirometry, evaluation of symptom burden and risk for future exacerbations with on-going monitoring, assessment for features of asthma, and comprehensive management, both non pharmacologic and pharmacologic. CAT = COPD assessment test; MRC = Medical Research Council; SABD PRN = short-acting bronchodilator as needed; AECOPD = acute exacerbation of COPD; Inhaled Long-Acting Therapies = long-acting muscarinic antagonist and/or long-acting B2-agonist and/or inhaled corticosteroid; LTOT = long-term oxygen therapy.

Table 1. CTS COPD Position Statement PICO questions.

PICO 1: How does a clinician choose appropriate maintenance pharmacotherapies in patients with stable COPD to improve dyspnea, exercise tolerance, physical activity and health status?
PICO elements
Population	Intervention(s)	Comparator	Outcomes
Adults with stable COPD^*, chronic bronchitis, emphysema	Maintenance inhaled therapy, alone or in combination: short-acting anticholinergic, short-acting beta-agonists, long-acting bronchodilators, long-acting beta-agonists, long-acting anticholinergic, long-acting muscarinic antagonists, inhaled corticosteroids, dual long-acting bronchodilators, combination ICS/LABA, triple therapy; oral therapy, alone or in combination(s): methylxanthines, theophylline, antibiotics, n-acetylcysteine, PDE-4 inhibitors, roflumilast.	Placebo, combination therapies compared to single modality, head to head comparison	Dyspnea, exercise, exercise tolerance, exercise capacity, health-related quality of life
PICO 2: How does a clinician choose appropriate maintenance pharmacotherapies in patients with stable COPD to reduce the risk of frequent exacerbations?
Adults with stable COPD^*, chronic bronchitis, emphysema	Maintenance inhaled therapy, alone or in combination: short-acting anticholinergic, short-acting beta-agonists, long-acting bronchodilators, long-acting beta-agonists, long-acting anticholinergic, long-acting muscarinic antagonists, inhaled corticosteroids, dual long-acting bronchodilators, combination ICS/LABA, triple therapy; oral therapy, alone or in combination(s): methylxanthines, theophylline, antibiotics, n-acetylcysteine, PDE-4 inhibitors, roflumilast.	Placebo, combination therapies compared to single modality, head to head comparison	Exacerbations requiring change in medication (antibiotic and/or prednisone), ER and hospital admissions/readmissions, time to first exacerbation, exacerbation rate
PICO 3: How does a clinician approach the treatment of patients who have both Asthma and COPD (including the definition of ACO, assessment and management differences)?
Adults with asthma-COPD symptoms —greater than 40 years of age; Asthma-COPD Overlap Syndrome (ACOS); Asthma-COPD Overlap (ACO); eosinophils and COPD assessment and/or management; eosinophils and ACO/ACOS	Maintenance inhaled therapy: long acting anticholinergic; short acting anticholinergic alone and in combination with short-acting beta-agonists; inhaled corticosteroids; long-acting beta-agonists; combination of long-acting anticholinergic, inhaled corticosteroids, and long-acting beta-agonists; should not include short acting reliever medications (short-acting beta agonists alone)	Placebo, combination therapies compared to single modality, head to head comparison	Any outcome

* Stable COPD meaning not currently having an exacerbation

Table 2. Literature search results informing recommendations.

Section	Topic	Abstracts reviewed, n	Abstracts accepted for full review, n	Publications informing recommendations for practice, n (references)
PICO 1	How does a clinician choose appropriate maintenance pharmacotherapies in patients with COPD to improve dyspnea, exercise tolerance, physical activity and health status?	689	156	111
PICO 2	How does a clinician choose appropriate maintenance pharmacotherapies in COPD to reduce the risk of frequent exacerbations?	237	88	88
PICO 3	How does a clinician approach the treatment of patients who have both Asthma and COPD (including the definition of ACO, assessment and management differences)?	269	54	2

Figure 2. COPD Pharmacotherapy. Suggested COPD pharmacotherapy promoting an approach that matches treatment decisions with symptom burden and risk of future exacerbations. Solid arrows indicate step up therapy to optimally manage symptoms of dyspnea and/or activity limitation, as well as the prevention of AECOPD where appropriate. Dashed arrows indicate potential step down of therapy, with caution, and with close monitoring of the patient symptoms, exacerbations and lung function. Frequent AECOPD is ≥2 events requiring antibiotics ± systemic corticosteroids over 2 years; or ≥1 Severe AECOPD requiring hospitalization. As-needed (prn) use of short-acting bronchodilator should accompany all recommended therapies. CAT = COPD assessment test; MRC = Medical Research Council; SABD prn = short-acting bronchodilator as needed; AECOPD = acute exacerbation of COPD; LAMA = long-acting muscarinic antagonist; LABA = long-acting B2-agonists; ICS = inhaled corticosteroid; PDE₄ = phosphodiesterase-4.

Table 3. Proposed assessment and diagnostic criteria of patients suspected of having ACO.

Assessment of a Patient with suspected ACO	1. Risk factors for COPD
Must be asked	2. Symptoms compatible with COPD (ex. cough, sputum, dyspnea and/or exercise limitation, exacerbations)
	3. History of Allergy and/or Atopy, Asthma (defined as a. history of asthma in childhood, physician diagnosed asthma, wheeze, exacerbations, previously documented physiology)
	4. Pre and post bronchodilator spirometry
Diagnostic criteria of ACO	1. Diagnosis of COPD (includes risk factors, symptoms and spirometry)
The following are required:	2. History of Asthma (ex. previous diagnosis, current or previous symptoms in keeping with asthma, physiologic confirmation)
	3. On Spirometry, the presence of persistent post bronchodilator fixed airflow obstruction (FEV1/FVC <0.7)
The following are supportive but are not required:	1. Documentation (either current or previous) of an acute bronchodilator improvement in the FEV1 of 12% and >200 ml
	2. Sputum eosinophils >3%
	3. Blood eosinophils (current or previously documented) >300 cells/µL