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<sup>1</sup> Drugs limited to those available in U.S., listed in alpha order.<br> • <b>Not recommended:</b> Mucolytics [D], regular antitussive use [D], long-term oral/inhaled steroid monotherapy [A], antibiotics other than for infectious exacerbations [B]. Adding SABA in high doses to LABA not recommended. Oral steroid trial: No evidence supports short-term PO steroid trial to identify steroid-responsive pts.<br>
• <b>Combo BDs</b> from different classes may ↑ efficacy, ↓ side effects.<br>
• <b>Dosing steroid/LABA combos:</b> Once-daily vs twice-daily dosing doesn’t show relevant differences in efficacy.<br>
• <b>Roflumilast:</b> Reduces mod/severe exac in corticosteroid-tx pts w/ chronic bronchitis, severe/very severe COPD, and hx exacerbations [A]; no direct comparisons/add-on studies of roflumilast and inhaled steroids; always use in combo w/ ≥1 long-acting BD.<br>
• No existing COPD med has conclusively been shown to modify lung-function decline long-term.
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<sup>2</sup> Category D = more sx, high exacerbation risk. Exacerbation = acute worsening (beyond day-to-day variation) leading to change in medication.
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<sup>3</sup> Long-term O<sub>2</sub> tx indications: If sat ≤88% (or PaO<sub>2</sub> ≤55mmHg) (w/ or w/o hypercapnia) 2x in 3wks [B]or if sat 88% (or PaO<sub>2</sub> 55-60 mmHg) w/ pulm HTN, edema suggesting CHF, or Hct >55% [D].
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<sup>4</sup> If severe emphysema w/ upper lobe dz + low post-rehab exercise capacity: LVRS shows improved survival (54% vs 40%); [A] however, LVRS shows no survival benefit in those w/ post-high rehab exercise capacity. LVRS shows higher mortality vs medical mgmt in pts w/ FEV1 ≤20% predicted who have either homogeneous dz on HRCT or DLCO ≤20% predicted.
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<sup>5</sup> Refer for txp eval if COPD w/ BODE index >5. Listing criteria includes BODE 7-10 plus ≥1 of these: [C]<br>
• Hx exac w/ hypercapnia (PCO<sub>2</sub> >50 mmHg)<br>
• Pulm HTN and/or cor pulmonale despite O<sub>2</sub> tx<br>
• FEV1 <20% predicted w/ either DLCO <20% predicted or homogenous emphysema distribution<br>
GOLD BODE reference: Celli BR, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. <i>N Engl J Med.</i> 2004;350(10):1005-12. <a href=http://www.nejm.org/doi/pdf/10.1056/NEJMoa021322>PDF</a> <a href=http://www.ncbi.nlm.nih.gov/pubmed/14999112>PubMed® abstract</a>
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<sup>6</sup> Long-term NIV in stable very severe dz and hypercapnia: Insufficient evidence to formulate recommendations. Combo NIV + long-term O<sub>2</sub> may be useful in select pts, esp pts w/ daytime hypercapnia. In COPD pts w/ OSA, CPAP has clear benefits.
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<sup>7</sup> Brief cessation counseling:<br>
• <b>Ask</b> @ tobacco use @ every visit for tobacco users; use office-wide identification system<br>
• <b>Advise</b> quitting in a clear, strong, personalized manner<br>
• <b>Assess</b> willingness to quit, determine when (eg, w/in next 30 days)<br>
• <b>Assist</b> w/ quit plan, including practical counseling, exploring social support, prescribing pharmaco-tx, educational resources<br>
• <b>Arrange</b> follow-up in person or via phone, etc.
• <b>Combo BDs</b> from different classes may ↑ efficacy, ↓ side effects.<br>
• <b>Dosing steroid/LABA combos:</b> Once-daily vs twice-daily dosing doesn’t show relevant differences in efficacy.<br>
• <b>Roflumilast:</b> Reduces mod/severe exac in corticosteroid-tx pts w/ chronic bronchitis, severe/very severe COPD, and hx exacerbations [A]; no direct comparisons/add-on studies of roflumilast and inhaled steroids; always use in combo w/ ≥1 long-acting BD.<br>
• No existing COPD med has conclusively been shown to modify lung-function decline long-term.
<br><br>
<sup>2</sup> Category D = more sx, high exacerbation risk. Exacerbation = acute worsening (beyond day-to-day variation) leading to change in medication.
<br><br>
<sup>3</sup> Long-term O<sub>2</sub> tx indications: If sat ≤88% (or PaO<sub>2</sub> ≤55mmHg) (w/ or w/o hypercapnia) 2x in 3wks [B]or if sat 88% (or PaO<sub>2</sub> 55-60 mmHg) w/ pulm HTN, edema suggesting CHF, or Hct >55% [D].
<br><br>
<sup>4</sup> If severe emphysema w/ upper lobe dz + low post-rehab exercise capacity: LVRS shows improved survival (54% vs 40%); [A] however, LVRS shows no survival benefit in those w/ post-high rehab exercise capacity. LVRS shows higher mortality vs medical mgmt in pts w/ FEV1 ≤20% predicted who have either homogeneous dz on HRCT or DLCO ≤20% predicted.
<br><br>
<sup>5</sup> Refer for txp eval if COPD w/ BODE index >5. Listing criteria includes BODE 7-10 plus ≥1 of these: [C]<br>
• Hx exac w/ hypercapnia (PCO<sub>2</sub> >50 mmHg)<br>
• Pulm HTN and/or cor pulmonale despite O<sub>2</sub> tx<br>
• FEV1 <20% predicted w/ either DLCO <20% predicted or homogenous emphysema distribution<br>
GOLD BODE reference: Celli BR, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. <i>N Engl J Med.</i> 2004;350(10):1005-12. <a href=http://www.nejm.org/doi/pdf/10.1056/NEJMoa021322>PDF</a> <a href=http://www.ncbi.nlm.nih.gov/pubmed/14999112>PubMed® abstract</a>
<br><br>
<sup>6</sup> Long-term NIV in stable very severe dz and hypercapnia: Insufficient evidence to formulate recommendations. Combo NIV + long-term O<sub>2</sub> may be useful in select pts, esp pts w/ daytime hypercapnia. In COPD pts w/ OSA, CPAP has clear benefits.
<br><br>
<sup>7</sup> Brief cessation counseling:<br>
• <b>Ask</b> @ tobacco use @ every visit for tobacco users; use office-wide identification system<br>
• <b>Advise</b> quitting in a clear, strong, personalized manner<br>
• <b>Assess</b> willingness to quit, determine when (eg, w/in next 30 days)<br>
• <b>Assist</b> w/ quit plan, including practical counseling, exploring social support, prescribing pharmaco-tx, educational resources<br>
• <b>Arrange</b> follow-up in person or via phone, etc.
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Long-acting inhaled bronchodilator<sup>1</sup> +/- additional agents, assess for O<sub>2</sub> tx, consider surgery (COPD Category D)<sup>2</sup>