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.

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

Exacerbations per year: ≤ 1 not leading to hospitalisation

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.

mMRC: 0-1

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

CAT: < 10

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

Reminder: Stop SAMA treatment when prescribing a LAMA

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

Exacerbations per year: ≤ 1 not leading to hospitalisation

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.

mMRC: ≥ 2

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

CAT: ≥ 10

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.