Notes on Initial treatment

Group A

• All patients should receive a bronchodilator
• Short- or long-acting bronchodilator acceptable
• Long-acting preferred if affordable and available

Group B

• First-line: LABA + LAMA combination
• Use if no issues with cost, availability, or side effects
• If LABA + LAMA not suitable:
  • Either LABA or LAMA may be used
  • Choice based on individual symptom relief

Group E

• First-line: LABA + LAMA combination
• Use if no issues with cost, availability, or side effects
• LABA + ICS is not encouraged in COPD
• If ICS is indicated:
  • LABA + LAMA + ICS preferred over LABA + ICS
• Consider initial LABA + LAMA + ICS if eosinophils ≥ 300 cells/μL

Group E

• ICS benefit for exacerbation prevention correlates with blood eosinophil count
• COPD with concomitant asthma:
  • Treat as asthma; ICS is mandatory
• Prescribe rescue short-acting bronchodilator for all patients

Notes on some medications

Ensifentrine

• FDA-approved inhaled medication for COPD maintenance
• Dual PDE3/4 inhibitor: relaxes airways, reduces inflammation, improves mucus clearance
• Eases wheezing, cough, and breathlessness
• Daily use, not for acute relief (not a rescue inhaler)
• Side effects: back pain, high blood pressure, diarrhea, and psychiatric warnings

Roflumilast

• Oral tablet medication for COPD with chronic bronchitis and history of exacerbations
• Selective PDE 4 inhibitor: reducing inflammation with anti-inflammatory effects.
• Side effects: nausea, diarrhea (early), headache, insomnia, weight loss.

Dupilumab

• Monoclonal antibody for moderate-to-severe COPD with eosinophilic inflammation (if chronic bronchitis)
• Inhibits IL-4 and IL-13 signaling pathways, reducing airway inflammation
• Improves lung function and reduces exacerbations in COPD patients
• Administered via subcutaneous injection every 2 weeks
• Side effects: injection site reactions, eye issues (conjunctivitis), cold sores

Mepolizumab

• Monoclonal antibody used for severe COPD with eosinophilic inflammation (with or without chronic bronchitis)
• Targets IL-5 to reduce eosinophil levels and airway inflammation
• Reduces exacerbations and improves lung function in COPD patients with high eosinophil counts
• Administered via subcutaneous injection once every 4 weeks
• Side effects: headaches, injection site reactions, back pain, and fever

Notes on Follow-up Assessment

Review, Assess and adjust if needed.

• Review
  • Symptoms (e.g., dyspnea)
  • Exacerbation risk (history, blood eosinophils)

• Assess
  • Inhaler technique and adherence
  • Role of non-pharmacological interventions

• Adjust
  • Escalate or de-escalate pharmacological therapy
  • Switch inhaler device or molecule if appropriate
  • Reassess clinical response and side effects after any change

Notes on Follow-up Treatment Algorithm

Consider the predominant treatable trait to target (dyspnea or exacerbations).

Use the exacerbation pathway if both exacerbations and dyspnea need to be targeted.

Notes on ICS

LABA + LAMA + ICS Treatment Considerations

• Do not withdraw ICS unless:
• ICS was started inappropriately
• No response to ICS
• Significant side effects or sever or recurrent pneumonia
• If blood eosinophils ≥ 300 cells/μL, discontinuation is linked to increased exacerbations

LABA + ICS Treatment Considerations

• Well-controlled with LABA + ICS (no asthma features): continuation is an option
• Further exacerbations:
• If eosinophil count ≥ 100 cells/μL: escalate to LABA + LAMA + ICS
• If eosinophil count < 100 cells/μL: switch to LABA + LAMA
• Major symptoms:
• Switch to LABA + LAMA or LABA + LAMA + ICS depending on prior ICS response