Copd: Stable Management

Key points

• General measures for everyone: smoking cessation (offer NRT, varenicline or bupropion) · annual influenza vaccine · one-off pneumococcal vaccine · pulmonary rehabilitation if functionally disabled (usually MRC grade 3 or above).
• First-line inhaler: a short-acting bronchodilator as required — SABA or SAMA.
• Still breathless or exacerbating → step up to DUAL long-acting therapy. Long-acting monotherapy is no longer a standard step.
• No asthmatic features → LABA + LAMA. Asthmatic or steroid-responsive features → LABA + ICS.
• Asthmatic/steroid-responsive features: any previous secure diagnosis of asthma or atopy · a higher blood eosinophil count · substantial variation in FEV1 over time (at least 400 ml) · substantial diurnal variation in peak flow (at least 20%).
• Still symptomatic or exacerbating on dual therapy → triple therapy (LAMA + LABA + ICS) · review at 3 months and step back to dual if there is no benefit, because ICS carries a pneumonia risk · for uncontrolled COPD with eosinophils ≥ 0.3 × 10⁹/l, mepolizumab or dupilumab are now NICE-approved add-ons (TA1166, TA1142).

Decision points in this pathway

• Still breathless or having exacerbations?
• Asthmatic or steroid-responsive features present?
• Still symptomatic or exacerbating on dual therapy?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.