Clinical Question

What are the best pharmacologic therapies for patients with different severity levels of stable chronic obstructive pulmonary disease (COPD)?

Bottom Line

These guidelines recommend stepping up from long-acting muscarinic antagonists (LAMAs) or long-acting beta₂ agonists (LABAs) to a LAMA/LABA combination, and then to a LAMA/LABA/inhaled corticosteroid (ICS) combination as the severity and number of acute exacerbations increases. (Level of Evidence = 1a)

Synopsis

The guideline from the Canadian Thoracic Society provides clear, actionable guidance for primary care physicians regarding the management of COPD. Its strengths include an evidence-based methodology, including systematic reviews and meta-analyses, to inform recommendations and evidence grading. Its limitations include the large number of financial and other conflicts of interests among panel members and the inclusion of only one primary care physician and one pharmacologist on the 16-member panel. The systematic reviews were organized around three outcomes: alleviating symptoms, reducing the risk of acute exacerbations, and reducing mortality. The panelists assessed severity based on the validated COPD Assessment Test (CAT; range = 0 to 40) and assessed dyspnea via the modified Medical Research Council (mMRC) scale: 1 = shortness of breath when hurrying on level ground or walking up a slight hill; 2 = walking slower because of shortness of breath or having to stop to catch breath; 3 = having to stoop after walking approximately 100 meters or after a few minutes; and 4 = too short of breath to leave the house.