testing or to predict response to inhaled
corticosteroid (ICS) in individuals. 2
Key opinion leaders and emerging research
suggest that there are disease phenotypes
(frequent exacerbator or persistent symptomatic
patient). 3 However, the place of inhaled triple
therapy (where ‘triple therapy’ refers to use of
long-acting beta agonist (LABA), long-acting
anti-muscarinic agent (LAMA) and ICS together),
asthma–COPD overlap management, role of
eosinophils 3 and role of macrolide antibiotics
in disease management are also important
considerations (which the guideline attempts to
address) but require longer term data to further
inform future practice. Updates in this guideline
have been made on the following: 2
• Investigations, including incidental findings
on CT scans – primary care review, advice for
patients to return if respiratory symptoms appear,
offering smoking cessation and discussing the
potential risk of lung cancer
• Prognosis – to avoid use of a multidimensional
index such as BODE to assess prognosis
• Inhaled therapies – to discuss risk of pneumonia
and ICS use with patients. Minimising the
number and types of inhalers patients use and
ensuring they are trained on use
• Oral phosphodiesterase 4 inhibitors are
mentioned in line with the associated 2017
technology appraisal
• Prophylactic antibiotics – recommendations
made on (unlicensed) use of azithromycin
• Oxygen therapy – eligibility of patients for and
risks of prescription (including short burst and
ambulatory use) and consideration for use in
pulmonary hypertension (noting this is not a
treatment for breathlessness and not effective for
isolated nocturnal hypoxaemia caused by COPD)
• Managing pulmonary hypertension and cor
pulmonale – advice on optimised therapies
• Lung volume reduction (LVR) surgery and
procedures – updated advice to increase uptake/
access
• Self-management/exacerbation plans –
developed in collaboration with patients and
carers.
These supplement the existing
recommendations on:
• diagnosing COPD using symptoms, spirometry
and other tests
• managing stable COPD using nebulisers, oral
therapy and pulmonary rehabilitation
• multidisciplinary management of stable COPD,
including physiotherapy, occupational therapy,
nutrition and palliative care
• managing exacerbations of COPD in primary
care and in hospital.
NICE has produced a visual summary alongside
the guidance, covering non-pharmacological
management and use of inhaled therapies (Figure
1). They also published concurrent antimicrobial
prescribing guidance for acute exacerbations of
COPD (December 2018).
The 2010 guidance inevitably steered patients
towards triple therapy (with LABA, LAMA and ICS)
with a greater emphasis on FEV1 (forced
expiratory volume in one second) value to guide
this. Early therapy started with a short-acting
bronchodilator progressing to a single long-acting
bronchodilator (evidence subsequently showed
superiority of LAMA over LABA use first line,
Non-
pharmacological
measures should
be optimised
alongside any
pharmacological
intervention and
before escalation
of therapy
especially in moderate–severe patients due to
lower incidence of exacerbations and adverse
effects with LAMA); 4,5 stepping up to dual long
acting agent and then addition of an ICS
(a suggestion which was based on expert opinion).
It is now apparent that as a result, some patients
were treated with ICS who may not have
warranted it. The new guidance still initiates
inhaled therapy with a short-acting
bronchodilator but progresses to long-acting
dual therapy.
The new guidance does not rely on FEV1 to
adjust therapy. One key change, stepping up after
short acting bronchodilator, is the initiation of
dual bronchodilator (LABA+LAMA) in preference
to a single long acting agent. For patients
exhibiting asthmatic features, the dual therapy
would be initiated with ICS and LABA rather than
LABA/LAMA [‘Where asthmatic features/features
suggesting steroid responsiveness in this context
include any previous secure diagnosis of asthma
or atopy, a higher blood eosinophil count,
substantial variation in FEV1 over time (at least
400ml) or substantial diurnal variation in peak
expiratory flow (at least 20%)’]. 2
Patients using long-acting therapy outside
of the December 2018 recommendations can
continue on current treatment and change after
review with a healthcare professional (HCP),
when both agree is appropriate.
NICE is undertaking a separate review on the
role of triple therapy in COPD (which was out of
scope of the initial guidance update). At time of
writing this article, the draft is undergoing public
consultation and final guidance is scheduled to be
published in Summer 2019. The draft 2019
guidance showed the proposed place of triple
therapy in patients who remain breathless
+/- exacerbate despite all other interventions
being optimised (noting consideration of a
three-month trial in those without asthmatic
features, reverting if ineffective). 6
Management
Management of COPD can be broadly divided
into two areas – non-pharmacological and
pharmacological.
Non-pharmacological
These measures should be optimised alongside
any pharmacological intervention and before
escalation of therapy:
• Pulmonary rehabilitation, especially
encouraging physical activity to minimise muscle
loss/deconditioning (which increases mortality)
• Optimised nutrition – dietetic input and
supplementation where applicable
• Social/occupational therapy input to retain
independence and enable activities of daily living
• Psychological support for anxiety and
depression +/- pharmacological treatment as
necessary 7,8
• Airways breathing control techniques to aid
energy conservation, management of panic/
anxiety
• Use of a hand-held fan may provide relief of
breathlessness. 9
Pharmacological
• Inhaled therapies initiated appropriate to the
stage of disease (Note any patients exhibiting
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