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The COPD tool for modifying pharmacological treatment - Tool 2

The patient is currently taking long-term inhaled medicines for the management of COPD and they are likely to benefit from escalation or de-escalation of treatment.

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Home Tool 1: treatment initiation Tool 2: modifying treatment

Step 1

Choose the patient’s predominant clinical trait requiring treatment

Step 2

Choose the patient’s current medicine regimen

Treatment recommendation for: Exacerbations & LAMA or LABA

Initiate a LABA/LAMA

OR

Consider a ICS + LABA if the patient's blood eosinophil count ≥ 0.3x109/L or blood eosinophil count ≥ 0.1x109/L AND ≥ 2 moderate exacerbations or ≥ 1 exacerbation with hospitalisation

N.B. The LABA needs to be taken concurrently with an ICS due to the increased risk of death associated with LABA monotherapy for patients with features of asthma.

Treatment recommendation for: Exacerbations & LABA/LAMA

Consider escalating to triple therapy if the patient continues to have exacerbations (two or more per year) despite adherence and optimal inhaler technique (NZ COPD guidelines 2021). Triple therapy could be achieved with a LABA/LAMA + ICS (two inhalers; no Special Authority approval required for the ICS) or a LABA/LAMA/ICS (one inhaler; Special Authority approval required).

N.B. A beneficial response to an ICS may be expected to occur in patients with a blood eosinophil count > 0.1 x 109/L.

OR

Consider referral to a respiratory physician for the addition of long-term azithromycin (250 mg per day - not funded) if the patient has a history of exacerbations and smoking.

Treatment recommendation for: Exacerbations & ICS + LABA

Consider escalating to triple therapy. This could be achieved with either a LABA/LAMA + ICS (two inhalers; no Special Authority approval required for the ICS) or a LABA/LAMA/ICS (one inhaler; Special Authority approval required).

OR

Consider withdrawing the ICS and adding a LAMA if the patient is at high risk of pneumonia, there is a lack of response to the ICS or the ICS is no longer considered appropriate

Treatment recommendation for: Exacerbations & LABA/LAMA + ICS

Assess inhaler technique and consider switching to single inhaler combination treatment if adherence is a concern (i.e. LABA/LAMA/ICS; Special Authority approval required)

OR

Consider de-escalating treatment by withdrawing the ICS if the patient is at high risk of pneumonia, there is a lack of response to the ICS or the ICS is no longer considered appropriate;

OR

Consider referral to a respiratory physician for the addition of long-term azithromycin (250 mg per day – not funded) if the patient has a history of exacerbations and smoking.

Treatment recommendation for: Breathlessness & LAMA or LABA

Initiate a LABA/LAMA

Treatment recommendation for: Breathlessness & LABA/LAMA

Investigate other potential causes of breathlessness, e.g. heart failure, and consider switching inhaler devices or changing to a different combination long-acting inhaler;

OR

Consider escalating to triple therapy. This could be achieved with either a LABA/LAMA + ICS (two inhalers; no Special Authority approval required for the ICS) or a LABA/LAMA/ICS (one inhaler; Special Authority approval required).

However, consider the increased risk of pneumonia with regular ICS treatment (NZ COPD guidelines 2021).

Treatment recommendation for: Breathlessness & LAMA + ICS

Consider escalating to triple therapy. This could be achieved with either a LABA/LAMA + ICS (two inhalers; no Special Authority approval required for the ICS) or a LABA/LAMA/ICS (one inhaler; Special Authority approval required).

OR

Consider withdrawing the ICS and adding a LAMA if the patient is at high risk of pneumonia, there is a lack of response to the ICS or the ICS is no longer considered appropriate

Treatment recommendation for: Breathlessness & LABA/LAMA + ICS

Investigate other potential causes of breathlessness, e.g. heart failure, and consider switching inhaler devices or changing to a different combination long-acting inhaler;

OR

Consider withdrawing the ICS if the patient is at high risk of pneumonia, there is a lack of response to the ICS or the ICS is no longer considered appropriate

Treatment recommendation for: Exacerbations and breathlessness & LAMA or LABA

Initiate a LABA/LAMA

OR

Consider a ICS + LABA if the patient's blood eosinophil count ≥ 0.3x109/L or blood eosinophil count ≥ 0.1x109/L AND ≥ 2 moderate exacerbations or ≥ 1 exacerbation with hospitalisation

N.B. The LABA needs to be taken concurrently with an ICS due to the increased risk of death associated with LABA monotherapy for patients with features of asthma.

Treatment recommendation for: Exacerbations and breathlessness & LABA/LAMA

Consider escalating to triple therapy if the patient continues to have exacerbations (two or more per year) despite adherence and optimal inhaler technique (NZ COPD guidelines 2021). Triple therapy could be achieved with a LABA/LAMA + ICS (two inhalers; no Special Authority approval required for the ICS) or a LABA/LAMA/ICS (one inhaler; Special Authority approval required).

N.B. A beneficial response to an ICS may be expected to occur in patients with a blood eosinophil count > 0.1 x 109/L.

OR

Consider referral to a respiratory physician for the addition of long-term azithromycin (250 mg per day - not funded) if the patient has a history of exacerbations and smoking.

Treatment recommendation for: Exacerbations and breathlessness & ICS + LABA

Consider escalating to triple therapy. This could be achieved with either a LABA/LAMA + ICS (two inhalers; no Special Authority approval required for the ICS) or a LABA/LAMA/ICS (one inhaler; Special Authority approval required).

OR

Consider withdrawing the ICS and adding a LAMA if the patient is at high risk of pneumonia, there is a lack of response to the ICS or the ICS is no longer considered appropriate

Treatment recommendation for: Exacerbations and breathlessness & LABA/LAMA + ICS

Assess inhaler technique and consider switching to single inhaler combination treatment if adherence is a concern (i.e. LABA/LAMA/ICS; Special Authority approval required)

OR

Consider de-escalating treatment by withdrawing the ICS if the patient is at high risk of pneumonia, there is a lack of response to the ICS or the ICS is no longer considered appropriate;

OR

Consider referral to a respiratory physician for the addition of long-term azithromycin (250 mg per day – not funded) if the patient has a history of exacerbations and smoking.

Tool 2: Escalating or de-escalating COPD treatment at follow-up

Tool 2 may be appropriate for any patient taking maintenance treatment for COPD; it is not used for initiating medicines. Before deciding if a change in medicines is required, the patient’s symptoms and exacerbation history should be reviewed. The patient’s adherence to non-pharmacological and pharmacological treatments and inhaler technique should also be assessed.

This tool is based on a second treatment algorithm for the escalation or de-escalation of COPD treatment that was initially released in 2019 by GOLD and updated in 2020 following concerns that the original ABCD system might be misinterpreted. It also includes updated guidance on the use of the blood eosinophil count as a biomarker to help predict which patients with COPD are most likely to benefit from treatment with an inhaled corticosteroid (ICS).

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Discussion

Gail Cowles 3 Apr 2023 06:53
Sharyn Willis, Medical Advisor, bpacnz 3 Apr 2023 14:14

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