American Thoracic Society Issues New Guidelines for COPD Treatments

New official guidelines have been published by the American Thoracic Society (ATS) for the treatment of chronic obstructive pulmonary disease (COPD).

Among the new recommendations, the combination of long-acting beta two agonists (LABA) and long-acting muscarinic antagonists (LAMA) is recommended over either therapy alone to treat people with COPD who have shortness of breath or exercise intolerance.

The guidelines were published in the American Journal of Respiratory and Critical Care Medicine, in an article titled “Pharmacologic Management of COPD: An Official American Thoracic Society Clinical Practice Guideline.”

Pharmacological treatment of COPD is intended to improve quality of life and reduce the frequency of exacerbations (disease worsening).

The new guidelines focus on questions related to COPD management that were not addressed in guidelines published in 2011. They were developed by a team of experts based on current scientific literature.

“The panel’s priority was to formulate questions that were of significant clinical importance to both healthcare providers and patients,” Linda Nici, MD, professor at Brown University and co-author of the new guidelines, said in a press release. “This clinical practice guideline is the most rigorous, outcome-driven distillation of the scientific literature to date.”

The guidelines were summarized in six main points.

First, in people with COPD who have dyspnea (shortness of breath) or exercise intolerance, the guidelines recommend the combination of LABA and LAMA over either LAMA or LABA alone.

LABA and LAMA are both classes of bronchodilators — medications that widen the airways within the lungs, which can ease breathing. Examples of LAMA medications include tiotropium, glycopyrronium, aclidinium, and umeclidinium; LABA medications include formoterol, salmeterol, indacaterol, and olodaterol.

The combination of LABA plus LAMA was the only “strong recommendation,” which the guideline experts defined as “the right course of action for [more than] 95% of patients.” The remaining five recommendations were “conditional,” defined as “the right course of action for [more than] 50% of patients.”

The second recommendation concerns individuals with COPD who experience dyspnea or exercise intolerance despite LABA/LAMA combination therapy. In these individuals, it is recommended that inhaled corticosteroids (ICS) — a type of inflammation-suppressing medication — be added to treatment.

The third recommendation is that, for people on the ICS/LABA/LAMA triple-therapy suggested in the second recommendation, ICS can be stopped after one year if the person does not experience exacerbations.

Fourth, in people with COPD who also have eosinophilia (a condition characterized by high levels of eosinophils, a type of immune cells), the guidelines recommend the addition of ICS to bronchodilators, but only if the person has had exacerbations in the past year. For people with COPD and eosinophilia, but no history of exacerbations, no recommendation for or against ICS use was made.

“The panel believed the quality of the available studies providing the evidence was not optimal, and hence the committee was reluctant to recommend ICS for all patients with COPD and blood eosinophilia,” the experts wrote, stressing a need for more studies to address this question.

The fifth recommendation pertains to individuals who experience frequent, severe exacerbations despite otherwise optimal therapy. In these individuals, the guidelines recommend oral corticosteroids as a maintenance therapy.

Finally, in people with COPD who experience advanced, refractory dyspnea, the guidelines suggest that opioids can be considered to manage this symptom.

It is important to note these guidelines reflect current understandings based on available scientific evidence; as such, they are necessarily limited by the evidence available. In general, the guidelines highlight the need for more studies.

However, even when studies are available, the data might not be reflective of all people with COPD, the experts noted. For instance, much of the data used for the guidelines came from clinical trials, which tend not to include certain patient populations. “Patients older than 80 years, those with multiple chronic conditions, and those with a co-diagnosis of COPD and asthma are rarely represented in clinical trials,” the researchers wrote.

Nonetheless, the team hopes “that clinicians and researchers will find this guideline useful.”

The experts stressed that the guidelines are not intended to be prescriptive, but to guide discussions on treatment that patients and their healthcare providers should have. “We recommend that for all clinical management decisions, the patient and the healthcare provider should engage in a shared decision-making process,” the team wrote.