Combination Therapy Options in Stable COPD

Christie Choo, PharmD, BCPS


US Pharmacist. 2010;35(7):1-4. 

In This Article

Current GOLD Guidelines

Updated in 2009, the GOLD guidelines recommend a stepwise approach ( TABLE 1 ) to treat patients based on severity of symptoms and airflow limitation as measured by forced expiratory volume in one second (FEV1).[2] (Spirometry values are further explained in FIGURE 1.[7]) Patients who fall into stage I (mild) should first be advised to quit smoking, which is the most clinically effective and cost-effective intervention to reduce the rates of COPD and halt its progression.[2] In addition to advising smoking cessation, the clinician should also educate patients on the importance of reducing occupational exposure to indoor and outdoor air pollution and other environment irritants, which may exacerbate symptoms and worsen the disease state. Lastly, patients should receive annual influenza vaccinations, as they have been demonstrated to reduce morbidity and mortality by as much as 50%.[2] Patients 65 years of age or older should also receive the pneumococcal polysaccharide vaccine, although the data regarding the utility of pneumococcal vaccination have been conflicting.[2]

Figure 1.

Spirometry values. The forced expiratory volume in one second (FEV1) and the FEV1/FVC (forced vital capacity) ratio determine the severity of COPD. FEV1 is used because it is reproducible and has been shown to be the most important predictor of prognosis in COPD.

As the disease progresses, it is inevitable that patients will require more than one agent to control their symptoms. In all stages of COPD, the patient begins the stepwise treatment with a short-acting bronchodilator (i.e., albuterol). Then as lung function declines, longer-acting agents like formoterol or tiotropium are added. Once the patient's FEV1 falls below 50%, an inhaled corticosteroid can be introduced.[2] The following section will delve deeper into the specific combinations that are used in stages II (moderate) and III (severe).


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.