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The COPD tool for modifying pharmacological treatment - Tool 1

The patient has been diagnosed with COPD but has not been prescribed long-term inhaled medicines to manage their condition

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The COPD prescribing tool for initiating medicines

This tool provides guidance on the initiation of medicines for patients with COPD based on their symptom severity and exacerbation history. This tool is NOT intended to be used for the escalation or de-escalation of treatment at follow-up (see Tool 2).

Choose category A, B, C or D which corresponds to the severity of the patient’s symptoms. Assessment criteria and treatment options are taken from the Global Strategy for the Diagnosis, Management and Prevention of COPD (GOLD 2020). An algorithm for the escalation or de-escalation of pharmacological treatment is available in GOLD, Figure 4.4, page 85.

This tool contains the updated recommendation that long-acting muscarinic antagonists (LAMAs) are generally preferred over long-acting beta2-agonists (LABAs) for patients requiring long-acting bronchodilator monotherapy as well as several funding changes for inhaled medicines.

Remember: Non-pharmacological interventions are first-line

In COPD management, non-pharmacological interventions are the most effective way to improve symptom control and quality of life and modify disease progression, regardless of what pharmacological treatments are ultimately required. Non-pharmacological interventions include:

  • Smoking cessation; the most important factor to improve symptoms and slow disease progression
  • Regular exercise; at least 20 – 30 minutes per day, ideally more if fitness allows
  • Pulmonary rehabilitation; offered to all patients where available, as it improves breathlessness substantially more than inhaled medicines (see Appendices 4 and 5 of the NZ COPD guidelines for some non-pharmacological strategies for breathlessness: https://www.nzrespiratoryguidelines.co.nz/copdguidelines.html)
  • Creating a written COPD action plan indicating what to do if the patient’s condition deteriorates - an example plan is provided in Appendix 3 of the NZ COPD guideline https://www.nzrespiratoryguidelines.co.nz/copdguidelines.html
  • Annual influenza immunisation and appropriate pneumococcal immunisation reduces the risk of serious respiratory infections and COPD exacerbations

Further information on pulmonary rehabilitation is available from: https://bpac.org.nz/2017/copd.aspx

Patient classification table

Patient category Characteristics Exacerbations per year mMRC CAT
A Less symptoms: low exacerbation risk ≤ 1 not leading to hospitalisation 0-1 < 10
B More symptoms: low exacerbation risk ≤ 1 not leading to hospitalisation ≥ 2 ≥ 10
C Less symptoms: high exacerbation risk ≥ 2, or 1 requiring hospitalisation 0-1 < 10
D More symptoms: high exacerbation risk ≥ 2, or 1 requiring hospitalisation ≥ 2 ≥10

Exacerbations

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

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 and is available from: www.catestonline.org/patient-site-test-page-english.html

mMRC

The modified Medical Research Council (mMRC) questionnaire 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 on 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

Acknowledgements

Acknowledgement Thank you to Dr Ben Brockway, Consultant & Senior Lecturer in Respiratory Medicine Southern DHB and University of Otago, for 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 LABA/LAMA 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/patient-site-test-page-english.html

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 or B ≤ 1 not leading to hospitalisation Low
C or D ≥ 2, or 1 requiring hospitalisation High

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

  • 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/patient-site-test-page-english.html

  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 OR a fixed-dose combination SABA / SAMA initially for “as needed” use OR a long-acting bronchodilator for patients with COPD who have few symptoms and a low risk of exacerbations; LAMAs are the recommended first-line long-acting bronchodilator with a LABA* second-line if a LAMA is contraindicated.

*Patients who are prescribed a LABA can continue to use a SABA for the short-term relief of symptoms.

IPRATROPIUM

Two puffs, as needed, up to four times daily

Atrovent

SALBUTAMOL

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

Respigen
Salair
Ventolin

TERBUTALINE

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

Bricanyl Turbuhaler

SALBUTAMOL + IPRATROPIUM

Two puffs, as needed, four times daily

Duolin

GLYCOPYRRONIUM

One inhalation, once daily

Breezhaler device with Seebri capsules

UMECLIDINIUM

One inhalation, once daily

Incruse Ellipta

TIOTROPIUM

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

Spiriva Respimat

TIOTROPIUM

One inhalation, once daily

Handihaler device with Spiriva capsules

SALMETEROL

Two puffs, twice daily

Serevent

SALMETEROL

One inhalation, twice daily

Serevent Accuhaler

INDACATEROL

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 6 Turbuhaler
Foradil and Oxis 6 are NOT dose equivalent

Each delivered dose of Oxis 6 Turbuhaler contains 4.5 micrograms per dose. The corresponding metered dose contains 6 micrograms eformoterol.

Foradil contains 12 micrograms per capsule for inhalation

Remember: Non-pharmacological interventions are first-line

In COPD management, non-pharmacological interventions, e.g. smoking cessation, exercise and pulmonary rehabilitation, are the most effective way to improve symptom control and quality of life and modify disease progression, regardless of what pharmacological treatments are ultimately required.

Further information on pulmonary rehabilitation is available from: https://bpac.org.nz/2017/copd.aspx

  • 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/patient-site-test-page-english.html

  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

Prescribe a LAMA OR alternatively a LABA* initially for patients with mild to moderate COPD and persistent breathlessness. This is appropriate for patients who are using a short-acting bronchodilator more than four times per day.

For patients with severe breathlessness consider a combination LABA/LAMA.

*If asthma and COPD overlap syndrome (ACOS) is suspected, an ICS/LABA is recommended as the initial treatment. LABA monotherapy in patients with asthma is associated with a small but significantly increased mortality risk.

GLYCOPYRRONIUM

One inhalation, once daily

Breezhaler device with Seebri capsules

UMECLIDINIUM

One inhalation, once daily

Incruse Ellipta

TIOTROPIUM

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

Spiriva Respimat

TIOTROPIUM

One inhalation, once daily

Handihaler device with Spiriva capsules

SALMETEROL

Two puffs, twice daily

Serevent

SALMETEROL

One inhalation, twice daily

Serevent Accuhaler

INDACATEROL

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 6 Turbuhaler
Foradil and Oxis 6 are NOT dose equivalent

Each delivered dose of Oxis 6 Turbuhaler contains 4.5 micrograms per dose. The corresponding metered dose contains 6 micrograms eformoterol.

Foradil contains 12 micrograms per capsule for inhalation

INDACATEROL + GLYCOPYRRONIUM

One inhalation, once daily

Breezhaler device with Ultibro capsule

OLODATEROL + TIOTROPIUM

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

Spiolto Respimat

VILANTEROL + UMECLIDINIUM

One inhalation, once daily

Anoro Ellipta

Remember: Non-pharmacological interventions are first-line

In COPD management, non-pharmacological interventions, e.g. smoking cessation, exercise and pulmonary rehabilitation, are the most effective way to improve symptom control and quality of life and modify disease progression, regardless of what pharmacological treatments are ultimately required.

Further information on pulmonary rehabilitation is available from: https://bpac.org.nz/2017/copd.aspx

  • 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/patient-site-test-page-english.html

  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 LAMA initially for patients who have few symptoms but a high risk of exacerbations.

GLYCOPYRRONIUM

One inhalation, once daily

Breezhaler device with Seebri capsules

UMECLIDINIUM

One inhalation, once daily

Incruse Ellipta

TIOTROPIUM

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

Spiriva Respimat

TIOTROPIUM

One inhalation, once daily

Handihaler device with Spiriva capsules

Remember: Non-pharmacological interventions are first-line

In COPD management, non-pharmacological interventions, e.g. smoking cessation, exercise and pulmonary rehabilitation, are the most effective way to improve symptom control and quality of life and modify disease progression, regardless of what pharmacological treatments are ultimately required.

Further information on pulmonary rehabilitation is available from: https://bpac.org.nz/2017/copd.aspx

  • 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/patient-site-test-page-english.html

  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 LAMA initially for patients who have many symptoms and a high risk of exacerbations.

For patients with severe breathlessness consider a combination LABA/LAMA.

For some patients, initial treatment with an ICS may be the first choice; this treatment is most likely to be effective in in patients with blood eosinophil counts ≥ 0.3 x 109/L.

GLYCOPYRRONIUM

One inhalation, once daily

Breezhaler device with Seebri capsules

UMECLIDINIUM

One inhalation, once daily

Incruse Ellipta

TIOTROPIUM

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

Spiriva Respimat

TIOTROPIUM

One inhalation, once daily

Handihaler device with Spiriva capsules

INDACATEROL + GLYCOPYRRONIUM

One inhalation, once daily

Breezhaler device with Ultibro capsule

OLODATEROL + TIOTROPIUM

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

Spiolto Respimat

VILANTEROL + UMECLIDINIUM

One inhalation, once daily

Anoro Ellipta

FLUTICASONE (FUROATE) + VILANTEROL

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

DuoResp Spiromax (200 + 6 or 400 + 12)

BUDESONIDE + FORMOTEROL

Two puffs of 200 + 6 micrograms, twice daily

Vannair (200 + 6)

Fluticasone furoate 200 micrograms + vilanterol 25 micrograms is for asthma only

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

One inhalation of 250 + 50 micrograms, twice daily

Seretide Accuhaler

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

Remember: Non-pharmacological interventions are first-line

In COPD management, non-pharmacological interventions, e.g. smoking cessation, exercise and pulmonary rehabilitation, are the most effective way to improve symptom control and quality of life and modify disease progression, regardless of what pharmacological treatments are ultimately required.

Further information on pulmonary rehabilitation is available from: https://bpac.org.nz/2017/copd.aspx

Published: 26 July 2016 | Updated: 22 February 2020

22 February 2020:
Updated to include new guidance from the 2021 Asthma and Respiratory Foundation of New Zealand COPD guidelines and funding changes.

8 June 2020:
Contains the updated recommendation from GOLD (2020) that long-acting muscarinic antagonists (LAMAs) are generally preferred over long-acting beta2-agonists (LABAs) for patients requiring long-acting bronchodilator monotherapy and several funding changes for inhaled medicines.

8 December 2017:
Revision based on updated GOLD guidance (2017); for details, see: www.bpac.org.nz/2017/copd-update.aspx

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