Long-acting inhaled bronchodilator1 superior to prn short-acting; assess for O2 tx (COPD Category B)2

¹ Drugs limited to those available in U.S., listed in alpha order. <br>• <b>Not recommended:</b> Mucolytics [D], regular antitussive use [D], long-term oral/inhaled steroid monotherapy [A], antibiotics other than for infectious exacerbations [B]. Adding SABA in high doses to LABA not recommended. Oral steroid trial: No evidence supports short-term PO steroid trial to identify steroid-responsive pts.<br>
• <b>Combo BDs</b> from different classes may ↑ efficacy, ↓ side effects.<br>
• <b>Dosing steroid/LABA combos:</b> Once-daily vs twice-daily dosing doesn’t show relevant differences in efficacy.<br>
• <b>Roflumilast:</b> Reduces mod/severe exac in corticosteroid-tx pts w/ chronic bronchitis, severe/very severe COPD, and hx exacerbations [A]; no direct comparison/add-on studies of roflumilast and inhaled steroids; always use in combo w/ ≥1 long-acting BD.<br>
• No existing COPD med has conclusively been shown to modify lung-function decline long-term.
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² Category B = more sx, low exacerbation risk. Exacerbation = acute worsening (beyond day-to-day variation) leading to change in medication.
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³ Long-term O₂ tx indications: If sat ≤88% (or PaO₂ ≤55mmHg) (w/ or w/o hypercapnia) 2x in 3wks [B] or if sat 88% (or PaO₂ 55-60mmHg) w/ pulm HTN, edema suggesting CHF, or Hct >55% [D]
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⁴ Brief cessation counseling:<br>
• <b>Ask</b> @ tobacco use @ every visit for tobacco users; use office-wide identification system<br>
• <b>Advise</b> quitting in a clear, strong, personalized manner<br>
• <b>Assess</b> willingness to quit, determine when (eg, w/in next 30 days)<br>
• <b>Assist</b> w/ quit plan, including practical counseling, exploring social support, prescribing pharmaco-tx, educational resources<br>
• <b>Arrange</b> follow-up in person or via phone, etc.