You’ll hear buzz about the updated Canadian COPD guidelines that will bring recommendations in line with global guidelines.
COPD is the third leading cause of death worldwide...and more exacerbations lead to a faster decline and more hospital admissions.
Ask patients about their symptoms and exacerbation history in the past year to help guide medication selection.
Patients with up to 1 exacerbation in the past year managed in the community are considered LOW risk for exacerbations...and those with 2 or more exacerbations or at least 1 that required a hospital visit are HIGH risk for exacerbations.
Mild symptoms and LOW risk of exacerbations. Recommend a long-acting beta-agonist (Serevent, etc) OR long-acting muscarinic antagonist (Spiriva, etc)...in addition to the usual prn short-acting bronchodilator (salbutamol, etc).
Moderate to severe symptoms and LOW risk of exacerbations. Recommend stepping up to a LABA/LAMA combo (Anoro, Inspiolto, etc). Previously the Canadian guidelines advised a single agent long-acting bronchodilator.
Using two long-acting agents improves symptoms and health status...and decreases exacerbations for patients with more persistent symptoms.
Moderate to severe symptoms and HIGH risk of exacerbations. Recommend a LABA/LAMA/ICS combo (Breztri, Trelegy) for these patients.
Point out that this differs from global guidelines that recommend a LABA/LAMA for high-risk patients before jumping to triple therapy. But triple therapy decreases exacerbations and may improve survival compared to dual therapy.
If triple therapy is not enough, consider adding long-term azithromycin for its anti-inflammatory effects...but advise ruling out QT prolongation and hearing impairment prior to starting.
Point out that azithromycin has better evidence of benefit than roflumilast or N-acetylcysteine.
Don’t recommend an inhaled corticosteroid (ICS) on its own or a LABA/ICS combo (Advair, etc) unless the patient also has asthma.
And avoid tapering off the ICS in stable patients on triple therapy...this may worsen COPD symptoms and increase exacerbations.
Advise using a single inhaler device for combos when possible...it’s easier to use...often less expensive...and may lead to lower rates of exacerbations and rescue med use. If you can’t avoid multiple inhalers, then suggest ones with the same administration technique.
Counsel your patients on proper inhaler technique, and emphasize smoking or vaping cessation if needed. And ask if they are current on their vaccinations (flu, COVID-19, pneumococcal, etc).
Go to our resource, Improving COPD Care, to get full details on strategies to help your patients.
- Bourbeau J, Bhutani M, Hernandez P, et al. 2023 Canadian Thoracic Society Guideline on Pharmacotherapy in Patients with Stable COPD. Canadian Journal of Respiratory, Critical Care and Sleep Medicine. DOI: 10.1080/24745332.2023.2231451. September 8, 2023. https://www.tandfonline.com/doi/full/10.1080/24745332.2023.2231451 (Accessed August 28, 2023).
- GOLD. 2023 GOLD Report. https://goldcopd.org/2023-gold-report-2/ (Accessed August 28, 2023).
- Toolbox: Improving COPD Care