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Helping patients with COPD breathe easier
Balanced information for better care
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2 Helping patients with COPD breathe easier
COPD is the fourth-leading cause of death1*
Older adults bear an increasing burden of disease.
Acute exacerbations account for 70% of COPD-related health care
costs, with admissions accounting for $15 billion.4
2010 2020
$32.1 Billion
$49.0 Billion
Projected increase
Economic impact of COPD
FIGURE 2. The financial burden of COPD is rising.3
*In the U.S., after cancer, heart disease, and accidental
injury.
FIGURE 1. People over 75 will make up over half of COPD patients
by 2030.2
55-64 years old
65-74 years old
75+ years old
FemaleMale
Nu
mb
er d
iag
no
sed
wit
h C
OP
D, i
n t
ho
usa
nd
s 80
60
40
20
02001 2005 2010 2015 2020 2025 2030
Observed Predicted
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Alosa Health | Balanced information for better care 3
Diagnose COPD accurately, using spirometry whenever possibleThe
diagnosis of COPD in patients with compatible symptoms is defined
by an obstructive pattern on spirometry, even after bronchodilator
treatment:
A significant FEV1 response to bronchodilators suggests asthma,
whether in conjunction with COPD (asthma-COPD overlap) or on its
own (if FEV1/FVC ≥0.7). Asthma is managed differently from
COPD.
During the COVID-19 pandemic, limited availability of spirometry
should not delay diagnosis and treatment. Try to obtain spirometry
as soon as feasible.
Forced Expiratory Volume in 1 second (FEV1)
Forced Vital Capacity (FVC)
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4 Helping patients with COPD breathe easier
LABA: long-acting beta agonist; LAMA: long-acting muscarinic
antagonist; ICS: inhaled corticosteroid
EXACERBATIONS:
Discrete episodes characterized by acute worsening of symptoms
(i.e., increased dyspnea, sputum volume, purulence) beyond usual
day-to-day variation and requiring intervention.
DAILY SYMPTOMS:
Defined according to either the mMRC scale,6 which focuses on
dyspnea (scores from 0-4), or the COPD Assessment Test [CAT]),7
which includes dyspnea and other symptoms (scores from 0-40). See
AlosaHealth.org/COPD for assessments.
Short-acting beta agonists (e.g., albuterol, levalbuterol)
and/or short-acting muscarinic antagonists (e.g., ipratropium) can
improve dyspnea and exercise tolerance. These medications should be
offered to patients in all GOLD groups as rescue inhalers.
Once an initial therapy has been selected (Figure 3),
adjustments may be needed depending on the progression of daily
symptoms and exacerbations. For dyspnea that is worsening or not
improving, follow Figure 4. For more frequent or continued
exacerbations, follow Figure 5.
FIGURE 3. Initial treatment choice should be based on daily
symptom severity and history of exacerbations, which define the
GOLD groups.5
FEWER DAILY SYMPTOMS mMRC 0-1 or CAT
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Alosa Health | Balanced information for better care 5
FIGURE 4. If dyspnea is worsening or not improving, consider
dual bronchodilators.5
If symptoms worsen or fail to improve
If symptoms worsen or fail to improve
* For patients already on ICS
• Consider switching devices or medications• Rule out or address
other causes of dyspnea
LABA + LAMA LABA + LAMA + ICS
LABA or LAMA LABA + ICS* ICS do not have a role for dyspnea
alone.
For dyspnea
For exacerbations
FIGURE 5. If exacerbations are increasing, use eosinophil levels
to guide treatment.5
LABA or LAMA
LABA + ICS
NAre eosinophils ≥300 cells/μL or
≥100 cells/μL with exacerbations**? Y
If additional exacerbation(s)
LABA + LAMA + ICS
If additional exacerbation(s)
LABA + LAMA
**2 moderate exacerbations or 1 exacerbation requiring
hospitalization
YNIf additional exacerbation(s),
are eosinophils ≥100 cells/μL?
Add roflumilast (if FEV1
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6 Helping patients with COPD breathe easier
Stop or replace ICS when appropriateRecent evidence shows that
ICS increase the risk of pneumonia.
FIGURE 7. Outpatient management of exacerbations5
Treat exacerbations with bronchodilators, oral steroids, and/or
antibiotics
Prescribe a short course of antibiotics for patients with
increased sputum
purulence and increased symptoms.
Prescribe steroids for 5 days (e.g., prednisone 40 mg) for
exacerbations not responding to bronchodilators.
Re-evaluate to modify therapy and/or hospitalize as
indicated.
Increase bronchodilator therapy for all patients (e.g.,
albuterol ± ipratropium).
+
Initiate or adjust maintenance treatment based on GOLD
recommendations (pages 4-5).
Gradual withdrawal of ICS does not trigger exacerbations. In the
WISDOM trial, a stepwise taper of ICS did not increase
exacerbations.9
In the FLAME trial, patients treated with ICS had a 50% relative
increase in the risk of pneumonia (4.8% with ICS vs 3.2% without
ICS).8 With similarly effective alternative treatments available,
ICS can safely be stopped in patients who do not have frequent
exacerbations or a high eosinophil count.
FIGURE 6. Reassessing the need for inhaled steroids5
*Monotherapy selection based on GOLD group and symptom
control.
Switch to LABA or LAMA* or
LABA + LAMA
Continue ICS
Y
Does the patient have any of the following?
• Recurrent pneumonia• No clear indication for ICS• Lack of
response to ICS N
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Alosa Health | Balanced information for better care 7
Intensify treatment when COPD advancesDual therapy: LABA+LAMA
reduces exacerbations more than LABA+ICS.
FIGURE 8. In the FLAME trial, LABA+LAMA reduced exacerbations
more than LABA+ICS, and prolonged the time to first
exacerbation.8
Pro
bab
ility
of
exac
erb
atio
n (
%)
Week
0 6 12 19 26 32 39 45 52
Moderate or severe
Hazard ratio, 0.84 (95% CI, 0.78–0.91) p
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8 Helping patients with COPD breathe easier
Helping patients quit smoking is keySmoking cessation is the
most effective intervention to delay COPD symptoms, the onset of
disability, and mortality.
FIGURE 10. Smoking and decline of lung function in COPD12
Age (years)
100
75
50
25
25 50 750
Never smoked or not susceptible to smoke
Stopped smoking at age 45
Stopped smoking at age 65
Death
Disability
Susceptible smoker
Create a plan for patients who are ready to quit.
Pharmacologic plus behavioral therapy offers the best prospects
for quitting. Multiple attempts may be needed.153
Encourage patients to call 1-800-QUIT-NOW (1-800-784-8669) or
text QUIT to 47848.
• Pharmacologic options include: — Nicotine replacement therapy:
long-acting (transdermal patch) and short- acting (e.g., gum,
lozenge, nasal spray, inhaler); available without prescription
— Prescriptions: varenicline (Chantix) OR bupropion (Wellbutrin,
generics)
• When starting nicotine replacement, use a long-acting plus a
short-acting agent.
• Varenicline is superior to bupropion and to long-acting
nicotine replacement alone.14
• Nicotine replacement can be combined with either bupropion or
varenicline.
Select treatment based on patient preferences, medical
conditions, and cost.2
Provide or refer for behavioral support. Even brief, simple
advice increases the likelihood of quitting. More intensive advice
can result in higher quit rates.131
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Alosa Health | Balanced information for better care 9
Additional interventions for patients with COPD
Pulmonary rehabilitation5
This is one of the most cost- effective interventions for COPD.
A 6- to 8-week program of twice weekly exercise training can
reduce:
• dyspnea• symptoms of anxiety and depression• readmissions in
patients with a
recent COPD hospitalization
Pneumococcal vaccination16
• Give Pneumovax (23-valent) once before age 65 and again at or
after age 65.
• Discuss Prevnar (13-valent). Consider giving in patients with
advanced disease given low risk and small incremental benefit.
Criteria for home oxygen in severe disease:
• O2 saturation ≤88% or PaO2 ≤55 mm Hg, or• PaO2 of 55-59 mm Hg
with evidence of pulmonary hypertension,
cor pulmonale, hematocrit >55%, or
• PaO2 ≥60 mm Hg with exercise desaturation, sleep desaturation
not corrected by continuous positive airway pressure (CPAP), or
severe dyspnea that responds to oxygen therapy.19
Note: When titrating oxygen, aim for an O2 saturation
>90%.
Prescribe oxygen in patients with chronic hypoxemia.17,18
Engage COPD patients in conversations about palliative care.
• COPD is a progressive disease that does not have a cure.• It
causes worsening symptoms, deteriorating quality of life, frequent
emergency room
visits, and hospitalizations.20
• Patients with end-stage COPD are far less likely than lung
cancer patients to get palliative medications.
• In patients with end-stage COPD, low-dose opioids can help
relieve refractory dyspnea without increasing the risk of
death.21,22
A conversation about palliative care for COPD should focus on
enhancing quality of life, optimizing function, and helping
patients and families get the emotional and spiritual support they
need.5
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10 Helping patients with COPD breathe easier
Prices of these regimens vary widely
Prices from goodrx.com, May 2020. Listed doses are based on
Defined Daily Doses by the World Health Organization and should not
be used for dosing in all patients. All doses shown are for
generics when available, unless otherwise noted. These prices are a
guide; patient costs will be subject to copays, rebates, and other
incentives.
Not all inhalers are FDA approved to treat COPD.
FIGURE 11. Cost of an inhaler or 30-day drug supply
Patents on devices make many regimens very costly, even those
including generic drugs.
SABA albuterol 90 mcg (Proair HFA, Proventil HFA, Ventolin HFA)
$69
albuterol 90 mcg (generic HFA) $45
levalbuterol 45 mcg (Xopenex HFA) $81
levalbuterol 45 mcg (generic HFA) $54
ipratropium 17 mcg (Atrovent HFA) $436
olodaterol 2.5 mcg (Striverdi Respimat) $269
salmeterol 50 mcg (Serevent Discus) $432
aclidinium 400 mcg (Tudorza Pressair) $672
tiotropium 18 mcg (Spiriva Handihaler) $505
tiotropium 18 mcg (Spiriva Respimat) $508
umeclidinium 62.5 mcg (Incruse Ellipta) $403
budesonide 180 mcg (Pulmicort Flexhaler) $271
beclomethasone 80 mcg (QVAR Redihaler) $281
fluticasone 250 mcg (Flovent Discus) $283
fluticasone 220 mcg (Flovent HFA) $427
fluticasone 232 mcg (Armonair Digihaler) $233
fluticasone 200 mcg (Arnuity Ellipta) $285
mometasone 440 mcg (Asmanex Twisthaler) $245
mometasone 400 mcg (Asmanex HFA) $247
albuterol/ipratropium (Combivent Respimat) $504
formoterol 12 mcg/aclidinium 400 mcg (Duaklir Pressair)
$1,218
formoterol 4.8 mcg/glycopyrrolate 9 mcg (Bevespi Aerosphere)
$415
olodaterol 2.5 mcg/tiotropium 2.5 mcg (Stiolto Respimat)
$495
valanterol 25 mcg/umeclidinium 62.5 mcg (Anoro Ellipta) $499
formoterol 4.5 mcg/budesonide 160 mcg (Symbicort) $392
formoterol 4.5 mcg/budesonide 160 mcg (generic) $282
formoterol 5 mcg/mometasone 100 mcg (Dulera) $350
salmeterol 21 mcg/fluticasone 115 mcg (Advair HFA) $434
salmeterol 50 mcg/fluticasone 250 mcg (Advair Discus) $433
salmeterol 50 mcg/fluticasone 250 mcg (Wixela Inhub) $170
salmeterol 50 mcg/fluticasone 250 mcg (generic) $171
vilanterol 25 mcg/fluticasone 100 mcg (Breo Ellipta) $408
vilaterol 25 mcg/umeclidinium 62.5 mcg/ fluticasone 100 mcg
(Trelegy Ellipta) $635
varenicline 2 mg (Chantix) $469
bupropion SR 300 mg (generic) $30
bupropion SR 300 mg (Wellbutrin SR) $502
bupropion SR 300 mg (Zyban) $253
bupropion XL 300 mg (generic) $37
nicotine inhaler (Nicotrol) $518
nicotine gum 4 mg (Nicorette) $29
nitotine patch 14 mg (e.g., Nicoderm CQ) $61
$400$200 $500$300$1000 $600
SAMA
LABA
LAMA
ICS
SABA+SAMA
LABA+LAMA
LABA+ICS
LABA+LAMA+ICS
roflumilast 0.5 mg (Daliresp) $418PDE-4 inhibitor
Smoking cessation
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Alosa Health | Balanced information for better care 11
References: (1) Centers for Disease Control and Prevention,
National Center for Health Statistics. Underlying Cause of Death
1999-2018 on CDC WONDER Online Database.
http://wonder.cdc.gov/ucd-icd10.html. Published 2020. Accessed May
12, 2020. (2) Khakban A, Sin DD, FitzGerald JM, et al. The
Projected Epidemic of Chronic Obstructive Pulmonary Disease
Hospitalizations over the Next 15 Years. A Population-based
Perspective. Am J Respir Crit Care Med. 2017;195(3):287-291. (3)
Centers for Disease Control and Prevention. COPD costs. Updated
February 21, 2018. Accessed June 24, 2020. (4) Press VG, Konetzka
RT, White SR. Insights about the economic impact of chronic
obstructive pulmonary disease readmissions post implementation of
the hospital readmission reduction program. Curr Opin Pulm Med.
2018;24(2):138-146. (5) Global Initiative for Chronic Obstructive
Lung Disease. Global strategy for the diagnosis, management, and
prevention of chronic obstructive pulmonary disease. 2020 report.
(6) Stenton C. The MRC breathlessness scale. Occup Med (Lond).
2008;58(3):226-227. (7) Jones PW, Harding G, Berry P, Wiklund I,
Chen WH, Kline Leidy N. Development and first validation of the
COPD Assessment Test. Eur Respir J. 2009;34(3):648-654. (8)
Wedzicha JA, Banerji D, Chapman KR, et al.
Indacaterol-Glycopyrronium versus Salmeterol-Fluticasone for COPD.
N Engl J Med. 2016;374(23):2222-2234. (9) Magnussen H, Disse B,
Rodriguez-Roisin R, et al. Withdrawal of inhaled glucocorticoids
and exacerbations of COPD. N Engl J Med. 2014;371(14):1285-1294.
(10) Rabe KF, Martinez FJ, Ferguson GT, et al. Triple Inhaled
Therapy at Two Glucocorticoid Doses in Moderate-to-Very-Severe
COPD. N Engl J Med. 2020;383(1):35-48. (11) Lipson DA, Barnhart F,
Brealey N, et al. Once-Daily Single-Inhaler Triple versus Dual
Therapy in Patients with COPD. N Engl J Med.
2018;378(18):1671-1680. (12) Fletcher C, Peto R. The natural
history of chronic airflow obstruction. Br Med J.
1977;1(6077):1645-1648. (13) Stead LF, Buitrago D, Preciado N,
Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for
smoking cessation. Cochrane Database Syst Rev.
2013;2013(5):Cd000165. (14) Anthenelli RM, Benowitz NL, West R, et
al. Neuropsychiatric safety and efficacy of varenicline, bupropion,
and nicotine patch in smokers with and without psychiatric
disorders (EAGLES): a double-blind, randomised, placebo-controlled
clinical trial. Lancet. 2016;387(10037):2507-2520. (15) van Eerd
EA, van der Meer RM, van Schayck OC, Kotz D. Smoking cessation for
people with chronic obstructive pulmonary disease. Cochrane
Database Syst Rev. 2016;2016(8):Cd010744. (16) Centers for Disease
Control and Prevention. Pneumococal vaccine recommendations.
https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html.
Accessed June 16, 2020. (17) Continuous or nocturnal oxygen therapy
in hypoxemic chronic obstructive lung disease: a clinical trial.
Nocturnal Oxygen Therapy Trial Group. Ann Intern Med.
1980;93(3):391-398.(18) Long term domiciliary oxygen therapy in
chronic hypoxic cor pulmonale complicating chronic bronchitis and
emphysema. Report of the Medical Research Council Working Party.
Lancet. 1981;1(8222):681-686. (19) U.S. Department of Health and
Human Services, U.S. Centers for Medicare and Medicaid Services
(CMS), Medicare Learning Network. Home oxygen therapy. CMS.
Accessed June 23, 2020. (20) Iyer AS, Goodrich CA, Dransfield MT,
et al. End-of-Life Spending and Healthcare Utilization Among Older
Adults with Chronic Obstructive Pulmonary Disease. Am J Med. 2019.
(21) Currow DC, Quinn S, Greene A, Bull J, Johnson MJ, Abernethy
AP. The longitudinal pattern of response when morphine is used to
treat chronic refractory dyspnea. J Palliat Med.
2013;16(8):881-886. (22) Ekström MP, Bornefalk-Hermansson A,
Abernethy AP, Currow DC. Safety of benzodiazepines and opioids in
very severe respiratory disease: national prospective study. BMJ.
2014;348:g445.
Visit AlosaHealth.org/COPDfor links to a comprehensive evidence
document and other resources.
Key messages
• Use spirometry to diagnose COPD.
• Classify patients based on daily symptoms and history of
exacerbations according to the GOLD classification system, which
can guide treatment.
• Adjust the regimen based on daily symptoms and
exacerbations.
• For patients who smoke, assess their willingness to quit and
tailor recommendations to their stage of readiness.
• Include non-drug interventions throughout the course of
COPD:
— Recommend exercise, good nutrition, and immunizations for all
patients.
— Refer selected patients to pulmonary rehabilitation.
• Treat acute exacerbations with short-acting bronchodilators,
systemic steroids, and an antibiotic when indicated.
• Begin conversations about palliative and end-of-life care as
the disease worsens.
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This material was produced by William Feldman, M.D., D.Phil.,
Fellow in Pulmonary and Critical Care Medicine; Michael A. Fischer,
M.D., M.S., Associate Professor of Medicine (principal editor);
Jerry Avorn, M.D., Professor of Medicine; and Dae Kim, M.D., Sc.D.,
Associate Professor of Medicine, all at Harvard Medical School; and
Ellen Dancel, Pharm.D., M.P.H., Director of Clinical Materials
Development at Alosa Health. Drs. Avorn, Feldman, and Fischer are
physicians at the Brigham and Women’s Hospital, and Dr. Kim
practices at the Beth Israel Deaconess Medical Center and Hebrew
Senior Life, all in Boston. None of the authors accepts any
personal compensation from any drug company.
Medical writer: Stephen Braun.
These are general recommendations only; specific clinical
decisions should be made by the treating clinician based on an
individual patient’s clinical condition. More detailed information
on this topic is provided in a longer evidence document at
AlosaHealth.org.
About this publication
The Independent Drug Information Service (IDIS) is supported by
the PACE Program of the Department of Aging of the Commonwealth of
Pennsylvania.
This material is provided by Alosa Health, a nonprofit
organization which is not affiliated with any pharmaceutical
company. IDIS is a program of Alosa Health.
Copyright 2020 by Alosa Health. All rights reserved. Aug
2020
