Key learning points

  • Spirometry remains the method of choice for confirming a diagnosis of COPD in patients who have appropriate signs and symptoms along with a recent chest X-ray and full blood count.
  • LABA and LAMA is the best dual therapy for patients without asthmatic features or features suggesting steroid responsiveness who remain breathless or have exacerbations on a SABA
  • An ICS and a LABA should be considered for patients with asthmatic features or features suggesting steroid responsiveness whose symptoms are not controlled on a SABA
  • Triple therapy with LABA, LAMA and ICS should be considered for any patients on dual therapy who are still limited by breathlessness or who experience one severe or two moderate exacerbations in a year 
  • Systemic corticosteroids should not be used for more than 5 days to manage exacerbations

Introduction

The NICE guideline on the diagnosis and management of COPD was comprehensively updated in December 2018.1 However, some information on inhaled triple therapy for managing stable COPD and the duration of systemic corticosteroids for managing exacerbations were not included in this guidance – so NICE reviewed the evidence and produced a further update in July 2019 with new recommendations in these areas.1 

Most people with COPD in the UK do not receive a diagnosis until they are over 50, therefore the guideline aims to ‘help people with COPD to receive a diagnosis earlier so that they can benefit from treatments to reduce symptoms, improve quality of life and keep them healthy for longer’.1 

The most recent version gives up to date recommendations on diagnosis and prognosis. It covers inhaled combination therapy, prophylactic antibiotic therapy, oxygen therapy as well as managing pulmonary hypertension and cor pulmonale. There is a section on lung surgery and lung volume reduction procedures, and self-management, education and telehealth monitoring.

This article will focus on the main changes of note for those working in primary care relating to the diagnosis and pharmacological management of COPD, including the 2019 recommendations about triple inhaled therapy for stable COPD and systemic corticosteroids for managing exacerbations, but does not attempt to cover all updates to the guidance.

Diagnosis

Not much has changed in the recommendations for diagnosis, which should be based on a compatible history along with examination, a recent chest X-ray and full blood count, with spirometry as the gold standard test for confirming the diagnosis.2 It is concerning therefore that a 2019 study found that many patients had been wrongly diagnosed with COPD because they had not had spirometry testing and were prescribed COPD medication, often inhaled corticosteroids, unnecessarily.3

A somewhat controversial addition to the 2018 update is the recommendation that patients should be referred to primary care for respiratory review and spirometry when an incidental finding of suspected COPD is found on a chest X-ray or CT scan.1 

Although the more cases of COPD that are picked up at an early stage the better, spirometry is not funded in the majority of general practices in the UK, and across the UK at the moment capacity to get a timely spirometry test is being challenged both in primary and secondary care. 

Prognosis

The use of multidimensional indices to assess prognosis are not recommended at this time. However, the factors associated with prognosis are listed and may be used to help guide discussions about a patient’s prognosis and treatment options (Box 1).

Box 1. Prognostic factors for patients with stable COPD1

  • FEV1
  • Smoking status
  • Breathlessness (MRC scale)
  • Chronic hypoxia and/or cor pulmonale
  • Low BMI
  • Severity and frequency of exacerbations
  • Hospital admissions
  • Symptom burden (eg COPD Assessment Test score)
  • Exercise capacity (eg 6-minute walk test)
  • TLCO (gas transfer) test
  • Whether the person meets the criteria for long-term oxygen therapy and/or home non-invasive ventilation
  • Multimorbidity
  • Frailty

Management

NICE produced a useful visual summary to accompany the guideline, which clearly outlines recommended non-pharmacological management and use of inhaled therapies for patients diagnosed with COPD (Figure 1).4

Figure 1. Non-pharmacological management and use of inhaled therapies

Patients who require inhaled therapy should be treated initially with short-acting bronchodilators (SABAs or SAMAs) as needed. If they are still breathless or have exacerbations, their treatment should then be guided by whether or not they have asthmatic features/features suggesting steroid responsiveness (a previous secure diagnosis of asthma or atopy, a higher blood eosinophil count, substantial variation in FEV1 over time of at least 400 ml or substantial diurnal variation in peak expiratory flow of at least 20%).1,4 

Patients without asthmatic features/features suggesting steroid responsiveness should be offered dual therapy with a long-acting beta2 agonist (LABA) and long-acting muscarinic antagonist (LAMA). This combination has been shown to provide the greatest benefit to patients’ overall quality of life, while being the most cost-effective option.1,4  

The 2019 update recommends that a 3-month trial of LABA + LAMA + inhaled corticosteroid (ICS) should be considered for those without asthmatic features whose daily symptoms adversely affect their quality of life. The ICS should be discontinued is symptoms do not improve. The same triple therapy combination should be considered for those without asthmatic features who experience one severe or two moderate exacerbations in a year.1,4 

For patients with asthmatic features/features suggesting steroid responsiveness, a LABA together with an ICS should be considered because of the likely benefit of ICS in this phenotype. If patients still have daily symptoms that adversely affect their quality of life or have one severe or two moderate exacerbations in a year on this combination, a LAMA can be offered in addition.1,4

Further treatment options should be explored for all patients on triple therapy who are still limited by breathlessness or experience frequent exacerbations.1,4 

If a patient’s symptoms are currently well controlled on a different regimen, such as LABA or LAMA monotherapy, they do not need to change to the recommended regimen until a change in their condition necessitates it.1For all inhaled therapies, it is recommended to keep the number and type of inhalers a patient uses to a minimum, as well as ensure that their prescription specifies the brand and inhaler they have been trained to use.1

Oral corticosteroids for managing exacerbations

The 2019 update recommends that the use of systemic corticosteroids for managing exacerbations should be limited to 5 days to reduce the risks associated with long-term corticosteroid use.1

“The latest NICE guidance on COPD has managed to maintain a simplicity that makes sense to most clinicians. It clarifies the importance of dual bronchodilation to improve symptoms and to reduce exacerbations, as well as the importance of inhaled corticosteroids in people with a significant asthma component or high eosinophil counts. It still highlights the importance of smoking cessation and immunisation against influenza and pneumococcus, as well as pulmonary rehabilitation.”

Dr Steve Holmes, GP with an interest in respiratory medicine and education lead for the Primary Care Respiratory Society

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