Pharmacologic Management of Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline

Abstract

Background: This document provides clinical recommendations for the pharmacologic treatment of chronic obstructive pulmonary disease (COPD). It represents a collaborative effort on the part of a panel of expert COPD clinicians and researchers along with a team of methodologists under the guidance of the American Thoracic Society. Methods: Comprehensive evidence syntheses were performed on all relevant studies that addressed the clinical questions and critical patient-centered outcomes agreed upon by the panel of experts. The evidence was appraised, rated, and graded, and recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Conclusions: The task force made recommendations regarding the pharmacologic treatment of COPD based on currently available evidence. 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.

COPD Maintenance Therapy with Tiotropium/Olodaterol Compared with Tiotropium: An Analysis in the Absence of Additional ICS Therapy

“…The results of the present analysis support the current ATS and NICE guidance regarding bronchodilation of patients with COPD [2,3]. The ATS recommends LAMA/ LABA combination therapy over monotherapy for patients who complain of dyspnea or exercise intolerance [2], while NICE recommends dual LAMA/LABA for patients who experience COPD symptoms despite optimized non-pharmacologic management and use of short-acting bronchodilators [3].…”

“…Inhaled corticosteroids (ICS) should be reserved for patients with high eosinophil counts (>300 cells/mL) and with a history of frequent exacerbations (!2 moderate exacerbations or >1 severe exacerbation in the previous year) [1]. Furthermore, the American Thoracic Society (ATS) recommends dual bronchodilation in patients with COPD who experience dyspnea or exercise intolerance [2]. The National Institute for Health and Care Excellence (NICE) recommends dual LAMA/LABA therapy in patients with COPD with no indication of asthmatic features or corticosteroid responsiveness who remain breathless or have exacerbations despite optimized non-pharmacologic management and use of short-acting bronchodilators [3].…”

Opioids for Dyspnea in Chronic Obstructive Pulmonary Disease: Short on the Details

“…Along with the overall pooled estimate, it would have been helpful for Nici et al (1) to concurrently present such important details, in order to provide readers with a more comprehensive and balanced view of their meta-analysis. When considering the results of a meta-analysis, it is instructive to know if a positive signal is being driven by a majority of studies included, versus a small number, and if the latter case, whether such studies might be associated with bias.…”

“…The authors also overlook acknowledging two other recently published meta-analyses on the topic of opioids for dyspnea in COPD (3,4), using nearly the same evidence base, and yet reporting strikingly different findings. Considering 10 out of 12 trials that Nici et al 1 On such an important and controversial topic as using opioids to treat refractory dyspnea in COPD, in a guideline document, it behoved Nici et al (1) to provide readers much more detail about their meta-analysis, including what, why and how data got pooled.…”

The Potential Role and Regulatory Mechanisms of MUC5AC in Chronic Obstructive Pulmonary Disease

“…In case of more severe dyspnea, severe airflow obstruction, and lung hyperinflation, combining LAMA with a selective long-acting beta2-agonist (LABA) is recommended [ 7 , 8 , 9 , 10 ]. If the symptoms and exacerbations persist (more than two exacerbations per year or one hospitalization for COPD), a LAMA, a LABA, and an inhaled corticosteroid (ICS) may be prescribed [ 11 , 12 , 13 , 14 ]. An array of other systemic therapies (azithromycin, roflumilast, xanthines, and antioxidants) may be considered as third-line treatments [ 1 ].…”