COPD Quick Reference

Read on for information about commonly-prescribed medications and their indications, when to prescribe supplemental oxygen, clinical integration care delivery, and more.

 

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Commonly Used Maintenance Medications in COPD

Generic Drug Name

Inhaler Type

Nebulizer

Oral

Injection

 Duration of Action
Beta2-Agonists
Short-Acting (SABA)

Levalbuterol

MDI

Yes

    

6-8 hours

Albuterol

MDI & DPI

Yes

Pill, syrup, extended release tablet

Yes

4-6 hours

12 hours (ext. release)

Terbutaline

DPI

  

Pill

Yes

4-6 hours
Long-Acting (LABA)

Formoterol

DPI

Yes

 

 

12 hours

Indacterol

DPI

  

 

  

24 hours

Olodaterol

SMI

  

 

  

24 hours

Salmeterol

MDI & DPI

 

 

 

12 hours
Anticholinergics
Short-Acting (SAMA)

Ipratroplum bromide

MDI

Yes

 

 

6-8 hours
Long-Acting (LAMA)

Aclidinium bromide

DPI & MDI

 

 

 

12 hours

Glycopyrronium bromide

DPI

 

Solution

Yes

12-24 hours

Tiotropium

DPI & SMI

 

 

 

24 hours

Umeclidium

DPI

 

 

 

24 hours
Combination Long-Acting Beta2-Agonist Plus Anticholinergic in One Device (LABA/LAMA)

Formoterol/aclidium

DPI

 

 

 

12 hours

Formoterol/glycopyrronium

MDI

 

 

 

12 hours

Indacaterol/ glycopyrronium

DPI

 

 

 

12-24 hours

Vilanterol /umeclidium

DPI

  

 

 

24 hours

Olodaterol/tiotropium

SMI

 

 

 

24 hours

  
Methylxanthines

Theophyline (SR)

 

 

Pill

Yes

Variable, up to 24 hours
Combination of Long-Acting Beta2-Agonist Plus Corticosteroids in One Device (LABA/ICS)

Formoterol/budesonide

MDI & DPI

 

 

 

12 hours

Formoterol/mometasone

MDI

  

 

 

12 hours

Salmeterol/fluticasone

MDI & DPI

 

 

 

12-24 hours

Vilanterol/fluticasone furoate

DPI

 

 

 

24 hours
Triple Combination in One Device (LABA/LAMA/ICS)

Fluticasone/umeclidium/vilanterol

DPI

 

 

 

 
Phosphodietrase-4 Inhibitors

Roflumilast

 

  

Pill

 

 

 

Abbreviations: FEV1, forced expiratory volume in 1 second; ICS , inhaled corticosteroids; LABA, long-acting ß2-agonist; LAMA, long-acting muscarinic receptor antagonist.

Reproduced with permission from the Global Initiative for Obstructive Lung Disease (GOLD), Global Strategy for the Diagnosis, Management and Prevention of COPD, 2017.

 

Pharmacologic Treatment Algorithms by GOLD Grade

APPROACH:

  • Classify by GOLD Criteria using Modified Medical Research Council (MMRC), COPD Assessment Test (CAT), and # of exacerbations and hospitalizations.
  • Patients must see a doctor at least four times (4x) per year for COPD management.

The Modified Medical Research Council (MMRC) Dyspnea Scale

Grade of Dyspnea

Description

0

Not troubled by breathlessness except on strenuous exercise

1

Shortness of breath when hurrying on the level or walking up a slight hill

2

Walks slower than people of the same age on the level because of breathlessness or has to stop for breath when walking at own pace on the level

3

Stops for breath after walking about 100 m or after a few minutes on the level

4

Too breathless to leave the house or breathless when dressing or undressing

 

Source: Mahler DA, Wells CK. Evaluation of clinical methods for rating dyspnea. Chest 1988; 93:580 - 586

 

COPD Assessment Test (CAT)

 

EXAMPLE

I am very happy

 0 1 X 3 4 5

I am very sad
 

I never cough

 0 1 2 3 4 5

I cough all the time
 

I have no phlegm (mucus) on my chest at all

 0 1 2 3 4 5

My chest is full of phlegm (mucus)
 

My chest does not feel tight at all

 0 1 2 3 4 5

My chest feels very tight
 

When I walk up a hill or flight of stairs I am not out of breath

 0 1 2 3 4 5

When I walk up a hillor flight of stairs I am completely out of breath
 

I am not limited to doing any activities at home

 0 1 2 3 4 5

I am completely limited to doing all activities at home
 

I am confident leaving my home despite my lung condition

 0 1 2 3 4 5

I am not confident leaving my home at all because of my lung condition
 

I sleep soundly

 0 1 2 3 4 5

I do not sleep soundly because of my lung condition
 

I have lots of energy

 0 1 2 3 4 5

I have no energy at all

TOTAL SCORE

 

Medication Guidelines (Groups A-D) Based on GOLD Classification

INITIAL PHARMACOLOGICAL TREATMENTS

At least 2 moderate exacerbations or at least 1 leading to hospitalization

Group C

LAMA

Group D

LAMA or LAMA + LABA* or ICS + LABA**

*Consider if highly symptomatic (e.g. CAT >20)

**Consider if eos is greater than or equal to 300

0 or 1 moderate exacerbations (not leading to hospitalization)

Group A

A bronchodilator

Group B

A long-acting bronchodilator (LABA or LAMA)
 

Dyspnea scale 0-1, CAT <10

Dyspnea scale greater than or equal to 2, CAT greater than or equal to 10

 

Abbreviations: FEV1, forced expiratory volume in 1 second; ICS, inhaled corticosteroids; LABA, long-acting ß2-agonist; LAMA, long-acting muscarinic receptor antagonist.

Reproduced with permission from the Global Initiative for Obstructive Lung Disease (GOLD), Global Strategy for the Diagnosis, Management and Prevention of COPD, 2017.

 

Non-Pharmacologic Management of COPD

Patients Group Essential Recommended Depending on Local Guidelines

A

Smoking cessation (can include pharmacologic treatment)

Physical activity

Flu vaccine

Pneumococcal vaccine

B-D

Smoking cessation (can include pharmacologic treatment)

Pulmonary rehabilitation

Physical activity

Flu vaccine

Pneumococcal vaccine

 

Prescription of Supplemental Oxygen to COPD Patients

  • Arterial hypoxemia defined as: PaO2 < 55 mmHg (8 kPa) or SaO2 < 88% or PaO2 > 55 but 60 mmHg (> 8 but < 8.5 kPa with right heart failure or erythrocytosis

  • Prescribe supplemental oxygen and titrate to keep SaO2 = 90%

  • Recheck in 60 to 90 days to assess:

    • If oxygen is still indicated

    • If prescribed supplemental oxygen is effective

Care Coordination in COPD at MSHS

  • Care Management

    • All patients should be evaluated by care management

    • Email mshpcmreferral@mountsinai.org or call 212-241-7228

    • Use the MSHP Care Management Referral in Epic (order #391414)

  • Behavioral Health

    • Patients should be screened for depression using the PHQ-2/PHQ-9 and referred to psychiatric services through their current care pathway depending on their clinic

  • Clinical Pharmacist

    • Pharmacists can be a key part of the care team for chronic disease management. They are credentialed providers that can prescribe and adjust medications through the Collaborative Drug Treatment Model

  • Palliative Care

    • Patients with COPD may be referred to one of two practices. The services provided at each location are identical; please choose the location that is most convenient to your patient

      • To make a referral to the Martha Stewart Center for Living at 1440 Madison Avenue, please call: 212-241-1446

      • To make a referral to the Martha Stewart Center for Living Downtown at Union Square, please call: 212-844-1712

Next Steps

Read the  Mount Sinai COPD Pathway for in-depth, evidence-based guidelines for managing your COPD outpatients

Explore Team-Based Care services available to you and your practice as a member of MSHP's Clinically Integrated Network

Need a consult? Connect with our experts

 

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