For stable COPD, initial therapy should be short-acting beta-2 agonists (SABA) and short-acting muscarinic antagonists (SAMA), used as necessary to relieve breathlessness and help the patient to exercise longer. If ICS are being considered, the patient should be aware of potential risks such as developing pneumonia.[4]

For more complex COPD, inhaled combination therapy may be considered, involving long-acting muscarinic antagonists (LAMA), long-acting beta-2 agonists (LABA), as well as ICS.

LAMA plus LABA may be appropriate for COPD confirmed by spirometry with no asthma-type or steroid-responsive symptoms for patients already using short-acting bronchodilators, or who remain breathless or have exacerbations. LABA plus ICS may be suitable for COPD with asthmatic features or steroid responsiveness.

LAMA plus LABA plus ICS is the next stage to consider, particularly if day-to-day symptoms are having an adverse impact life quality or there is a sever exacerbation requiring hospital treatment. It may also be appropriate if there have been two or more moderate exacerbations in the past 12 months.

If introducing a LAMA + LABA + ICS approach, it should be reviewed after three months to see if symptoms have improved. If they have not, then therapy should revert back to LAMA plus LABA.

When giving long-acting drugs, patients should be prescribed inhalers they have been trained to use by specifying the brand and inhaler type in prescriptions.