Table 1.

Stepwise approach to COPD pharmacotherapy

Step 1: Start short-acting agents
  • SAMA with or without SABA (scheduled or as needed)

Start at step 1 if
  • COPD is mild, or

  • there are cost barriers to LAMA or LABA use

Expected benefit:
  • relieves symptoms but might not decrease AECOPD and hospitalizations

Step 2: Reassess inhaler technique and start long-acting agents
  • LAMA with SABA as needed, or

  • LABA with SABA as needed with or without SAMA as needed

Start at step 2 if
  • COPD is moderate to severe Move to step 2 if

  • there is treatment failure in step 1

Expected benefit:
  • relieves symptoms; decreases AECOPD and hospitalizations

  • LAMA is often preferred

Step 3: Reassess inhaler technique and optimize long-acting agents
  • LAMA with LABA and with SABA as needed

  • LAMA and LABA-ICS and SABA as needed (if there is poor symptom control despite LAMA with LABA, or if there is frequent AECOPD)

Move to step 3 if
  • there is treatment failure in step 2

Expected benefit:
  • limited evidence vs LAMA alone; addition of LABA might further relieve symptoms; addition of LABA-ICS might decrease AECOPD and possibly improve symptoms

  • AECOPD—acute exacerbation of COPD, COPD—chronic obstructive pulmonary disease, ICS—inhaled corticosteroid, LABA—long-acting β-agonist, LAMA—long-acting muscarinic antagonist, SABA—short-acting β-agonist, SAMA—short-acting muscarinic antagonist.