ATS: Guideline for Pharmacologic Management of COPD

The American Thoracic Society (ATS) has published a clinical practice guideline for the pharmacologic management of chronic obstructive pulmonary disease (COPD). The guideline includes 6 recommendations that address significant COPD management issues, including how to treat patients with COPD who report having exercise intolerance or dyspnea.

“We hope that clinicians and researchers will find this guideline useful; however, it is important to apply these recommendations along with clinical assessments and shared decision-making to ensure that patients receive optimal clinical care,” the guideline authors wrote.

To develop the recommendations, a panel of expert COPD clinicians and researchers performed comprehensive evidence syntheses on relevant studies that had been published in the MEDLINE, Embase, or Cochrane Library databases from 1990 to January 2019. The studies’ quality of evidence was weighed, and the positive vs adverse clinical outcomes were assessed.

The guideline includes 1 strong recommendation, which is that clinicians prescribe long-acting β₂-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy to patients with COPD who report having dyspnea or exercise intolerance.

The 5 other recommendations are conditional; they are:

• Prescribe triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA over dual therapy with LABA/LAMA to patients with COPD who report having dyspnea or exercise intolerance despite dual therapy with LABA/LAMA and who have a history of 1 or more exacerbations in the last year requiring antibiotics, oral steroids, or hospitalization.
• Consider withdrawing ICS if a patient with COPD who is receiving triple therapy (ICS/LABA/LAMA) has had no exacerbations in the last year.
• Prescribe ICS as an additive therapy for patients with COPD and blood eosinophilia who have a history of 1 or more exacerbations in the last year requiring antibiotics or oral steroids or hospitalization. No recommendation was made for or against ICS as an additive therapy to long-acting bronchodilators for patients with COPD and blood eosinophilia alone.
• Do not prescribe maintenance oral corticosteroid therapy to patients with COPD and a history of severe and frequent exacerbations despite otherwise optimal therapy.
• Within a personalized shared decision-making approach, consider prescribing opioid-based therapy for dyspnea management to individuals with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy.

“Additional research in populations that are underrepresented in clinical trials is needed, including studies in patients with COPD 80 years of age and older, those with multiple chronic health conditions, and those with a codiagnosis of COPD and asthma,” according to the guideline authors.

—Colleen Murphy

Reference:

Nici L, Mammen MJ, Charbek E, et al; the American Thoracic Society Assembly on Clinical Problems. Pharmacologic management of COPD: an official American Thoracic Society clinical practice guideline [published online April 13, 2020]. Am J Respir Crit Care Med. doi:10.1164/rccm.202003-0625ST