The COPD prescribing tool

This tool provides pharmacological treatment options for patients with COPD based on their symptom severity.

Click on the panel A, B, C or D which corresponds to the severity of the patient’s symptoms. Assessment criteria are taken from the Global Strategy for the Diagnosis, Management and Prevention of COPD (GOLD 2016).*

For more information on classifying severity of symptoms, click on the corresponding term on the grid below, e.g. “Spirometric classification".

* Recent bpacnz articles have used a three-stage assessment criteria for patients with COPD based on COPD-X.

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Patient classification table

Patient category Characteristics Exacerbations per year Spirometric classification mMRC CAT
A Less symptoms: low exacerbation risk

≤ 1 not leading to hospitalisation

GOLD 1-2
FEV1 ≥ 50% predicted

0-1 < 10
B More symptoms: low exacerbation risk ≥ 2 ≥ 10
C Less symptoms: high exacerbation risk

≥ 2, or 1 requiring hospitalisation

GOLD 3-4
FEV1 < 50% predicted

0-1 < 10
D More symptoms: high exacerbation risk ≥ 2 ≥10

GOLD = Global Initiative for Chronic Obstructive Lung Disease | mMRC = modified Medical Research Council questionnaire | CAT = COPD Assessment Test

Acknowledgements

Thank you to Dr Ben Brockway, Consultant & Senior Lecturer in Respiratory Medicine Southern DHB and University of Otago, and Helen Cant, Clinical Pharmacist Tokoroa, for their assistance in producing this resource.

Acceptable combinations

There is risk of duplication of therapy given the range of inhalers now available. Green/Ticks represent acceptable combinations while Red/Crosses caution potential duplication.

Class medicine SABA SAMA SABA/SAMA LABA LAMA LAMA/LABA ICS/LABA
SABA Salbutamol
Terbutaline
SAMA Ipratropium
SABA / SAMA Salbutamol & Ipratropium
LABA Salmeterol
Formoterol
Indacaterol
Vilanterol (only available in combination)
Olodaterol (only available in combination)
LAMA Tiotropium
Glycopyrronium
Umeclidinium
LAMA / LABA Tiotropium & Olodaterol
Glycopyrronium & Indacaterol
Umeclidinium & Vilanterol
ICS / LABA Budesonide & Formoterol
Fluticasone propionate & Salmeterol
Fluticasone furoate & vilanterol

CAT

The COPD Assessment Test (CAT) is designed to quantify how COPD affects a patient’s life and how this changes over time.

CAT comprises eight questions and provides a measure of health status ranging from 0-40; it is available from: www.catestonline.org/english/indexEN.htm

mMRC

The modified Medical Research Council (mMRC) questionnaire is used for assessing the severity of breathlessness

mMRC Grade Symptoms
0 I only get breathless with strenuous exercise
1 I get short of breath when hurrying on the level or walking up a slight hill
2 I walk slower than people of the same age on flat ground because of breathlessness, or I have to stop for breath when walking at my own pace on the level
3 I stop for breath after walking about 100 metres or after a few minutes on the level
4 I am too breathless to leave the house or I am breathless when dressing or undressing

Exacerbations

An exacerbation is an acute event with worsening of symptoms, beyond normal day-to-day variation, that requires a change in medicine. If a patient has been admitted to hospital in the previous 12 months due to a COPD exacerbation they are considered high risk.

Patient category Exacerbations per year Exacerbation risk
A

≤ 1 not leading to hospitalisation

Low

B
C

≥ 2, or 1 requiring hospitalisation

High

D

Spirometric classification

Severity of airflow limitation in COPD based on post-bronchodilator FEV1 in patients with an FEV1/FVC < 0.7:

Category Severity FEV1
GOLD 1 Mild FEV1 ≥ 80% predicted
GOLD 2 Moderate 50% ≤ FEV1 < 80% predicted
GOLD 3 Severe 30% ≤ FEV1 < 50% predicted
GOLD 4 Very severe FEV1 < 30% predicted
  • Severity of airflow limitation in COPD based on post-bronchodilator FEV1 in patients with an FEV1/FVC < 0.7:

    Category Severity FEV1
    GOLD 1 Mild FEV1 ≥ 80% predicted
    GOLD 2 Moderate 50% ≤ FEV1 < 80% predicted
    GOLD 3 Severe 30% ≤ FEV1 < 50% predicted
    GOLD 4 Very severe FEV1 < 30% predicted
  • An exacerbation is an acute event with worsening of symptoms, beyond normal day-to-day variation, that requires a change in medicine. If a patient has been admitted to hospital in the previous 12 months due to a COPD exacerbation they are considered high risk.

  • The modified Medical Research Council (mMRC) questionnaire is used for assessing the severity of breathlessness

    mMRC Grade Symptoms
    0 I only get breathless with strenuous exercise
    1 I get short of breath when hurrying on the level or walking up a slight hill
    2 I walk slower than people of the same age on flat ground because of breathlessness, or I have to stop for breath when walking at my own pace on the level
    3 I stop for breath after walking about 100 metres or after a few minutes on the level
    4 I am too breathless to leave the house or I am breathless when dressing or undressing
  • The COPD Assessment Test (CAT) is designed to quantify how COPD affects a patient’s life and how this changes over time. CAT comprises eight questions and provides a measure of health status ranging from 0-40; it is available from: www.catestonline.org/english/indexEN.htm

  Fully subsidised without restriction

  Partially subsidised without restriction

  Prescription endorsement required for full subsidy

  Special Authority approval required for full subsidy

(A) Less symptoms: low exacerbation risk

Prescribe a SAMA OR a SABA for “as needed” use by patients with COPD who have few symptoms and a low risk of exacerbations.

For some patients in this category a fixed-dose combination SAMA/SABA for “as needed” use may be beneficial.


IPRATROPIUM

Two puffs, as needed, up to four times daily

Atrovent

SALBUTAMOL

One to two puffs, as needed, up to four times daily

TERBUTALINE

One to two inhalations, as needed, up to four times daily

Bricanyl Turbuhaler

IPRATROPIUM + SALBUTAMOL

Two puffs, as needed, four times daily

Duolin
  • Severity of airflow limitation in COPD based on post-bronchodilator FEV1 in patients with an FEV1/FVC < 0.7:

    Category Severity FEV1
    GOLD 1 Mild FEV1 ≥ 80% predicted
    GOLD 2 Moderate 50% ≤ FEV1 < 80% predicted
    GOLD 3 Severe 30% ≤ FEV1 < 50% predicted
    GOLD 4 Very severe FEV1 < 30% predicted
  • An exacerbation is an acute event with worsening of symptoms, beyond normal day-to-day variation, that requires a change in medicine. If a patient has been admitted to hospital in the previous 12 months due to a COPD exacerbation they are considered high risk.

  • The modified Medical Research Council (mMRC) questionnaire is used for assessing the severity of breathlessness

    mMRC Grade Symptoms
    0 I only get breathless with strenuous exercise
    1 I get short of breath when hurrying on the level or walking up a slight hill
    2 I walk slower than people of the same age on flat ground because of breathlessness, or I have to stop for breath when walking at my own pace on the level
    3 I stop for breath after walking about 100 metres or after a few minutes on the level
    4 I am too breathless to leave the house or I am breathless when dressing or undressing
  • The COPD Assessment Test (CAT) is designed to quantify how COPD affects a patient’s life and how this changes over time. CAT comprises eight questions and provides a measure of health status ranging from 0-40; it is available from: www.catestonline.org/english/indexEN.htm

  Fully subsidised without restriction

  Partially subsidised without restriction

  Prescription endorsement required for full subsidy

  Special Authority approval required for full subsidy

(B) More symptoms: low exacerbation risk

Add a LABA OR a LAMA for patients with mild to moderate COPD and persistent troublesome dyspnoea who do not have adequate symptom control using a short-acting bronchodilator.

For patients unable to achieve symptom control with a single long-acting bronchodilator consider a combination LABA/LAMA inhaler.


SALMETEROL

Two puffs, twice daily

Meterol

SALMETEROL

Two puffs, twice daily

Serevent

SALMETEROL

One inhalation, twice daily

Serevent Accuhaler

INDACATEROLNEW

One inhalation of 150 mg or 300 mg, once daily

Breezhaler device with Onbrez capsules

FORMOTEROL (eformoterol)

One inhalation of 12 micrograms, once daily or twice daily

Foradil capsules via Aerolizer device

FORMOTEROL (eformoterol)

Two inhalations of 6 micrograms, twice daily

Oxis Turbuhaler
Foradil and Oxis are NOT dose equivalent

Oxis contains 6 micrograms per dose

Foradil contains 12 micrograms per capsule for inhalation

UMECLIDINIUMNEW

One inhalation, once daily

Incruse Ellipta

TIOTROPIUMNEW

Two puffs, once daily. MDI delivered as a mist (non-propellant).

Spiriva Respimat

OLODATEROL + TIOTROPIUM NEW

Two puffs, once daily. MDI delivered as a mist (non-propellant).

Spiolto Respimat

UMECLIDINIUM + VILANTEROL NEW

One inhalation, once daily

Anoro Ellipta
  • Severity of airflow limitation in COPD based on post-bronchodilator FEV1 in patients with an FEV1/FVC < 0.7:

    Category Severity FEV1
    GOLD 1 Mild FEV1 ≥ 80% predicted
    GOLD 2 Moderate 50% ≤ FEV1 < 80% predicted
    GOLD 3 Severe 30% ≤ FEV1 < 50% predicted
    GOLD 4 Very severe FEV1 < 30% predicted
  • An exacerbation is an acute event with worsening of symptoms, beyond normal day-to-day variation, that requires a change in medicine. If a patient has been admitted to hospital in the previous 12 months due to a COPD exacerbation they are considered high risk.

  • The modified Medical Research Council (mMRC) questionnaire is used for assessing the severity of breathlessness

    mMRC Grade Symptoms
    0 I only get breathless with strenuous exercise
    1 I get short of breath when hurrying on the level or walking up a slight hill
    2 I walk slower than people of the same age on flat ground because of breathlessness, or I have to stop for breath when walking at my own pace on the level
    3 I stop for breath after walking about 100 metres or after a few minutes on the level
    4 I am too breathless to leave the house or I am breathless when dressing or undressing.
  • The COPD Assessment Test (CAT) is designed to quantify how COPD affects a patient’s life and how this changes over time. CAT comprises eight questions and provides a measure of health status ranging from 0-40; it is available from: www.catestonline.org/english/indexEN.htm

  Fully subsidised without restriction

  Partially subsidised without restriction

  Prescription endorsement required for full subsidy

  Special Authority approval required for full subsidy

(C) Less symptoms: high exacerbation risk

Prescribe a fixed-dose combination ICS/LABA OR a LAMA for patients who have few symptoms but a high risk of exacerbations.

An alternative treatment option is a combination LABA/LAMA.


FLUTICASONE (FUROATE) + VILANTEROL NEW

One inhalation, once daily

Fluticasone furoate 100 micrograms + vilanterol 25 micrograms (for COPD and asthma), (NOTE: Fluticasone furoate 200 micrograms + vilanterol 25 micrograms is for asthma only)

Breo Ellipta (100 + 25)

BUDESONIDE + FORMOTEROL

Two inhalations of 200 + 6 micrograms, twice daily OR One inhalation of 400 + 12 micrograms, twice daily

Symbicort Turbuhaler (200 + 6 or 400 + 12)

BUDESONIDE + FORMOTEROL

Two puffs of 200 + 6 micrograms, twice daily

Vannair (200 + 6)

Budesonide is half as potent as fluticasone therefore equivalence requires twice the strength per dose

Fluticasone furoate 100 micrograms inhaled ONCE daily is approximately equivalent to fluticasone propionate 250 micrograms TWICE daily

FLUTICASONE (PROPIONATE) + SALMETEROL

Two puffs of 125 + 25 micrograms (or up to two puffs of 250 + 25 micrograms unsubsidised), twice daily

Rexair, Seretide 125 + 25 (or 250 + 25)

FLUTICASONE (PROPIONATE) + SALMETEROL

One inhalation of 250 + 50 micrograms, twice daily

Seretide Accuhaler

Rexair and Seretide MDI are not dose equivalent with Seretide DPI Accuhaler because MDIs contain salmeterol 25 micrograms compared with Accuhalers which contain salmeterol 50 micrograms

MDI inhaler: TWO puffs, twice daily; or Accuhaler: ONE inhalation, twice daily

If additional inhaled corticosteroids (ICS) are required, change to the higher strength formulation or add a separate ICS

UMECLIDINIUMNEW

One inhalation, once daily

Incruse Ellipta

TIOTROPIUMNEW

Two puffs, once daily. MDI delivered as a mist (non-propellant).

Spiriva Respimat

OLODATEROL + TIOTROPIUM NEW

Two puffs, once daily. MDI delivered as a mist (non-propellant).

Spiolto Respimat

UMECLIDINIUM + VILANTEROL NEW

One inhalation, once daily

Anoro Ellipta
  • Severity of airflow limitation in COPD based on post-bronchodilator FEV1 in patients with an FEV1/FVC < 0.7:

    Category Severity FEV1
    GOLD 1 Mild FEV1 ≥ 80% predicted
    GOLD 2 Moderate 50% ≤ FEV1 < 80% predicted
    GOLD 3 Severe 30% ≤ FEV1 < 50% predicted
    GOLD 4 Very severe FEV1 < 30% predicted
  • An exacerbation is an acute event with worsening of symptoms, beyond normal day-to-day variation, that requires a change in medicine. If a patient has been admitted to hospital in the previous 12 months due to a COPD exacerbation they are considered high risk.

  • The modified Medical Research Council (mMRC) questionnaire is used for assessing the severity of breathlessness

    mMRC Grade Symptoms
    0 I only get breathless with strenuous exercise
    1 I get short of breath when hurrying on the level or walking up a slight hill
    2 I walk slower than people of the same age on flat ground because of breathlessness, or I have to stop for breath when walking at my own pace on the level
    3 I stop for breath after walking about 100 metres or after a few minutes on the level
    4 I am too breathless to leave the house or I am breathless when dressing or undressing.
  • The COPD Assessment Test (CAT) is designed to quantify how COPD affects a patient’s life and how this changes over time. CAT comprises eight questions and provides a measure of health status ranging from 0-40; it is available from: www.catestonline.org/english/indexEN.htm

  Fully subsidised without restriction

  Partially subsidised without restriction

  Prescription endorsement required for full subsidy

  Special Authority approval required for full subsidy

(D) More symptoms: high exacerbation risk

Prescribe a fixed-dose combination ICS/LABA OR a LAMA for patients who have many symptoms and a high risk of exacerbations.

For patients without adequate symptom control a fixed-dose combination ICS/LABA AND a LAMA is a further treatment option.


FLUTICASONE (FUROATE) + VILANTEROL NEW

One inhalation, once daily

Fluticasone furoate 100 micrograms + vilanterol 25 micrograms (for COPD and asthma), (NOTE: Fluticasone furoate 200 micrograms + vilanterol 25 micrograms is for asthma only)

Breo Ellipta (100 + 25)

BUDESONIDE + FORMOTEROL

Two inhalations of 200 + 6 micrograms, twice daily OR One inhalation of 400 + 12 micrograms, twice daily

Symbicort Turbuhaler (200 + 6 or 400 + 12)

BUDESONIDE + FORMOTEROL

Two puffs of 200 + 6 micrograms, twice daily

Vannair (200 + 6)

Budesonide is half as potent as fluticasone therefore equivalence requires twice the strength per dose

Fluticasone furoate 100 micrograms inhaled ONCE daily is approximately equivalent to fluticasone propionate 250 micrograms TWICE daily

FLUTICASONE (PROPIONATE) + SALMETEROL

Two puffs of 125 + 25 micrograms (or up to two puffs of 250 + 25 micrograms unsubsidised), twice daily

Rexair, Seretide 125 + 25 (or 250 + 25)

FLUTICASONE (PROPIONATE) + SALMETEROL

One inhalation of 250 + 50 micrograms, twice daily

Seretide Accuhaler

Rexair and Seretide MDI are not dose equivalent with Seretide DPI Accuhaler because MDIs contain salmeterol 25 micrograms compared with Accuhalers which contain salmeterol 50 micrograms

MDI inhaler: TWO puffs, twice daily; or Accuhaler: ONE inhalation, twice daily

If additional inhaled corticosteroids (ICS) are required, change to the higher strength formulation or add a separate ICS

UMECLIDINIUMNEW

One inhalation, once daily

Incruse Ellipta

TIOTROPIUMNEW

Two puffs, once daily. MDI delivered as a mist (non-propellant).

Spiriva Respimat

Published: 26 July 2016 | Updated:

Frat Yousif 7/08/2016 1:28:17 p.m.

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