NICE guidance - management of stable COPD

NICE recommendations on managing stable COPD

Smoking cessation

• all COPD patents still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity
• unless contraindicated, offer nicotine replacement therapy, varenicline or bupropion, as appropriate, to people who are planning to stop smoking combined with an appropriate support programme to optimise smoking quit rates for people with COPD
  • Varenicline is recommended within its licensed indications as an option for smokers who have expressed a desire to quit smoking and should normally be prescribed only as part of a programme of behavioural support

Inhaled therapy

• short-acting beta2 agonists (SABA) and short-acting muscarinic antagonists (SAMA)
  • short-acting bronchodilators, as necessary, should be the initial empirical treatment for the relief of breathlessness and exercise limitation
    
    
• inhaled corticosteroids (ICS)
  • be aware of the potential risk of developing side effects (including non-fatal pneumonia) in people with COPD treated with inhaled corticosteroids and be prepared to discuss with patients
  • do not use oral corticosteroid reversibility tests to identify which people should be prescribed inhaled corticosteroids, because they do not predict response to inhaled corticosteroid therapy
    
    
• inhaled combination therapy
  • inhaled combination therapy refers to combinations of long-acting muscarinic antagonists (LAMA), long-acting beta2 agonists (LABA) and inhaled corticosteroids (ICS)
    
    • LAMA+LABA should be offered to people who:
      • have spirometrically confirmed COPD and
      • do not have asthmatic features/features suggesting steroid responsiveness and
      • remain breathless or have exacerbations despite:
        • having used or been offered treatment for tobacco dependence if they smoke and
        • optimised non-pharmacological management and
        • relevant vaccinations and
        • using a short-acting bronchodilator
          
          
    • LABA+ICS should be considered for people who:
      • have spirometrically confirmed COPD an
      • have asthmatic features/features suggesting steroid responsiveness and
      • remain breathless or have exacerbations despite:
        • having used or been offered treatment for tobacco dependence if they smoke and
        • optimised non-pharmacological management and
        • relevant vaccinations and
        • using a short-acting bronchodilator
          
    • LAMA+LABA+ICS should be offered to people with COPD who are taking LAMA + LABA or LABA + ICS if:
      • they have a severe exacerbation (requiring hospitalisation) or
      • they have 2 moderate exacerbations within a year

Oral therapy

• oral corticosteroids
  • maintenance use of oral corticosteroid therapy in COPD is not normally recommended
  • some people with advanced COPD may need maintenance oral corticosteroids if treatment cannot be stopped after an exacerbation
    • if used then the clinician should keep the dose as low as possible, monitor for osteoporosis and offer prophylaxis
• theophylline
  • should be offered only after trials of short- and long-acting bronchodilators or to people who cannot use inhaled therapy
  • theophylline can be used in combination with beta2 agonists and muscarinic antagonists
  • reduce theophylline dose if macrolide or fluroquinolone antibiotics (or other drugs known to interact) are prescribed to treat an exacerbation
• mucolytic therapy
  • consider in people with a chronic productive cough and continue use if symptoms improve
  • do not routinely use to prevent exacerbations.
• oral phosphodiesterase-4 inhibitors
  • roflumilast, as an add-on to bronchodilator therapy, is recommended as an option for treating severe chronic obstructive pulmonary disease in adults with chronic bronchitis, only if:
    • the disease is severe, defined as a forced expiratory volume in 1 second (FEV1) after a bronchodilator of less than 50% of predicted normal, and
    • the person has had 2 or more exacerbations in the previous 12 months despite triple inhaled therapy with a long-acting muscarinic antagonist, a long-acting beta-2 agonist and an inhaled corticosteroid.
  • treatment with roflumilast should be started by a specialist in respiratory medicine
  • PDE4 inhibitors improve lung function and reduces moderate and severe exacerbations (2)
  • improve lung function and decreases exacerbations in patients who are on fixed-dose LABA/ICS combination (2)
    
• oral prophylactic antibiotic therapy
  • before starting prophylactic antibiotic therapy in a person with COPD, think about whether respiratory specialist input is needed
  • azithromycin (usually 250 mg 3 times a week) should be considered for people with COPD if they:
    • do not smoke and have optimised non-pharmacological management and inhaled therapies, relevant vaccinations and (if appropriate) have been referred for pulmonary rehabilitation and
    • continue to have 1 or more of the following, particularly if they have significant daily sputum production:
      • frequent (typically 4 or more per year)
      • exacerbations with sputum production
      • prolonged exacerbations with sputum production exacerbations resulting in hospitalisation
  • before offering prophylactic antibiotics, ensure that the person has had:
    • sputum culture and sensitivity (including tuberculosis culture), to identify other possible causes of persistent or recurrent infection that may need specific treatment (for example, antibiotic-resistant organisms, atypical mycobacteria or Pseudomonas aeruginosa)
    • training in airway clearance techniques to optimise sputum clearance
    • a CT scan of the thorax to rule out bronchiectasis and other lung pathologies
  • before starting azithromycin, ensure the person has had:
    • an electrocardiogram (ECG) to rule out prolonged QT interval and
    • baseline liver function tests
  • when prescribing azithromycin, advise people about the small risk of hearing loss and tinnitus, and tell them to contact a healthcare professional if this occurs
  • review
    • prophylactic azithromycin should be reviewed after the first 3 months, and then at least every 6months
    • only continue treatment if the continued benefits outweigh the risks. Be aware that there are no long-term studies on the use of prophylactic antibiotics in people with COPD
  • for people who are taking prophylactic azithromycin and are still at risk of exacerbations, provide a non-macrolide antibiotic to keep at home as part of their exacerbation action plan
  • be aware that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD

Reference:

• (1) National Institute for Health and Care Excellence (NICE) 2018. Chronic obstructive pulmonary disease in over 16s: diagnosis and management
• (2) Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2024. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease