Pharmacological treatment optimisation for stable COPD: an endless story?: Proposals from the Société de Pneumologie de Langue Française

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FIGURE 1
Proposed algorithm for the pharmacological therapeutic management of chronic obstructive pulmonary disease (COPD). For patients with exacerbations despite a long-acting bronchodilator but low levels of dyspnoea (modified Medical Research Council (mMRC) score <2), the choice can be either a long-acting β₂-agonists (LABA) plus long-acting muscarinic antagonists (LAMA) or an inhaled corticosteroids (ICS) plus LABA combination. For patients with dyspnoea on two long-acting bronchodilators, applicable components of the lowest box are theophylline and additional rehabilitation (since at this point, these patients should have already undergone rehabilitation as part of the “nonpharmacological treatment components” mentioned at the top of the figure). BD: bronchodilator; FEV₁: forced expiratory volume in 1 s; FVC: forced vital capacity; PDE4i: phosphodiestase-4 inhibitors. ^#: β₂-agonist or anticholinergic.
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FIGURE 2
Pharmacological treatment indications corresponding to the algorithm proposed in figure 1. Steps refer to maintenance therapy, as-needed short-acting bronchodilators being indicated in all patients. SABA: short-acting β₂-agonists; SAMA: short-acting muscarinic antagonists; LABA: long-acting β₂-agonists; LAMA: long-acting muscarinic antagonists; ICS: inhaled corticosteroids; mMRC: modified Medical Research Council.

TABLE 1

Measures that should accompany the implementation of pharmacological treatment recommendations

Situation	Action
COPD diagnosis	The diagnosis has to be spirometry-confirmed (post-bronchodilator FEV₁/FVC ratio <0.70)
In all patients	Smoking cessation assistance Vaccinations Physical activity advised Balanced diet Rehabilitation if persistent dyspnoea/disability despite appropriate medications On-demand short-acting bronchodilator(s) in case of dyspnoea Account for the patient's capabilities when choosing an inhalation device Reassess 1–3 months after therapy changes, then every 3–12 months At least annual lung function testing
If associated asthma	See asthma recommendations
Insufficient effect (persistent dyspnoea/disability and/or exacerbations under maintenance therapy)	Check Differential diagnosis Smoking cessation Pulmonary function Compliance/intake technique Therapeutic education/rehabilitation Comorbid conditions