A separate algorithm is provided for FOLLOW-UP treatment, where the management is based on two key treatable traits: persistence of dyspnea and occurrence of exacerbations
Figure 3.9 is available from Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2024. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease
The Figure above suggests escalation and de-escalation strategies based on available efficacy as well as safety data
The response to treatment escalation should always be reviewed, and de-escalation should be considered if there is a lack of clinical benefit and/or side effects occur.
De-escalation may also be considered in COPD patients receiving treatment who return with resolution of some symptoms that subsequently may require less therapy.
Patients, in whom treatment modification is considered, in particular de-escalation, should be undertaken under close medical supervision.
GOLD authors note that they are fully aware that treatment escalation has not been systematically tested; trials of de-escalation are also limited and only include ICS.
Follow-up pharmacological management
- The follow-up pharmacological treatment algorithm can be applied to any patient who is already taking maintenance treatment(s) irrespective of the GOLD group allocated at treatment initiation
- the need to treat primarily dyspnoea/exercise limitation or prevent exacerbations further should be evaluated.
- if a change in treatment is considered necessary then select the corresponding algorithm for dyspnoea or exacerbations; the exacerbation algorithm should also be used for patients who require a change in treatment for both dyspnoea and exacerbations.
Follow up pharmacological management should be guided by the principles of first review and assess, then adjust if needed:
Review
- Review symptoms (dyspnoea) and exacerbation risk.
Assess
- Assess inhaler technique and adherence, and the role of non-pharmacological approaches (covered later in this chapter).
Adjust
- Adjust pharmacological treatment, including escalation or de-escalation. Switching inhaler device or molecules within the same class (e.g. using a different long acting bronchodilator) may be considered as appropriate. Any change in treatment requires a subsequent reviewof the clinical response, including side effects.
Dyspnoea
- for patients with persistent breathlessness or exercise limitation on long-acting bronchodilator monotherapy, the use of two bronchodilators is recommended:
- if the addition of a second long acting bronchodilator does not improve symptoms, consider switching inhaler device or molecules
- at all stages, dyspnoea due to other causes (not COPD) should be investigated and treated appropriately. Inhaler technique and adherence should be considered as causes of inadequate treatment response.
Exacerbations
- for patients with persistent exacerbations on long-acting bronchodilator monotherapy, escalation to LABA + LAMA is recommended.
- in patients who develop further exacerbations on LABA+LAMA therapy we suggest escalation to LABA+LAMA+ICS
- a beneficial response after the addition of ICS may be observed at blood eosinophil cunts >= 100 cells/uL, with a greater magnitude of response more likely with higher eosinophil counts
- in patients treated with LABA+LAMA+ICS (or those with eos <100 cells/uL) who still have exacerbations the following options may be considered:
- add roflumilast. This may be considered in patients with an FEV1 <50% predicted and chronic bronchitis, particularly if they have experienced at least one hospitalisation for an exacerbation in the previous year
- add a macrolide. The best available evidence exists for the use of azithromycin, especially in those who are not current smokers. Consideration to the development of resistant organisms should be factored into decision-making
- stopping ICS. This can be considered if there are adverse effects (such as pneumonia) or a reported lack of efficacy. However, a blood eosinophil count >=300 cells/mul identifies patients with the greatest likelihood of experiencing more exacerbations after ICS withdrawal and who subsequently should be followed closely for relapse of exacerbations
Patients under treatment with LABA+ICS
- if a patient with COPD and no features of asthma has been treated - for whatever reason - with LABA+ICS and is well controlled in terms of symptoms and exacerbations, continuation with LABA+ICS is an option. However, if patient has:
- Further exacerbations: treatment should be escalated to LABA+LAMA+ICS if the blood eosinophil count is >=100 cells/uL or switched to LABA+LAMA if it is <100 cells/uL
- Major symptoms: switching to LABA+LAMA should be considered
Reference:
- Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2024. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease