CHESTGuidelines & Topic CollectionsEscalating Therapy in Patients With COPD Experiencing Exacerbations

Escalating Therapy in Patients With COPD Experiencing Exacerbations

When escalating therapy in patients with COPD experiencing exacerbations, it is recommended to assess their adherence to their current therapy and check their inhaler technique. Addressing patients’ comorbidities like cardiac disease and measuring their blood eosinophil count (BEC) is also advised.

Review other infographics in this series:
Initial Maintenance Therapy Selection for Patients With COPD »
Escalating Therapy in Patients With COPD Who Remain Symptomatic »

Author: Nick Hanania, MD, MS, FCCP

Last updated October 17, 2023

Scenario #1: Patient on existing long-acting β-agonist (LABA) or long-acting muscarinic antagonist (LAMA)

✓ Consider LABA/LAMA combination unless BEC is ≥300 cells/μL

✓ Consider LABA/LAMA/inhaled corticosteroid (ICS) if BEC ≥300 cells/μL

✓ Review and reassess response

Scenario #2: Patient on LABA + LAMA

✓ Consider LABA + LAMA + ICS if BEC ≥100 cells/μL

✓ Consider daily roflumilast if FEV1 <50% and chronic bronchitis

✓ Consider azithromycin, especially in ex-smokers

✓ Review and reassess response

Scenario #3: Patient on LABA + ICS

✓ Consider escalation to LABA + LAMA + ICS if patient is having further exacerbations

✓ Combination LABA + LAMA + ICS has been shown to be superior to LABA + ICS and would be the preferred choice if there is an indication for ICS

✓ If the patient has features of asthma, treatment should always contain an ICS

✓ Review and reassess response

Scenario #4: Patient on LABA + LAMA + ICS

✓ Consider daily roflumilast if FEV1 <50% and chronic bronchitis

✓ Consider azithromycin, especially in ex-smokers

✓ Consider de-escalation of ICS if pneumonia or other considerable side effects; if BEC ≥300 cells/μL, de-escalation is more likely to be associated with exacerbations

✓ Review and reassess response

Source: Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, 2023. www.goldcopd.org
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