Chronic obstructive pulmonary disease
Progressive airflow limitation linked to smoking and inhaled irritants. Diagnosis requires spirometry: post-bronchodilator FEV1/FVC < 0.7. Management is built on long-acting bronchodilators, with inhaled corticosteroids added for frequent exacerbations.
ICD-10 J4412 drugs
Also known as: COPD
Drugs used for this condition
- AAclidiniumFirst line · Long-acting muscarinic antagonist for inhalation (LAMA)Aclidinium is a LAMA for COPD maintenance. GOLD 2024 and GesEPOC 2021 place the LAMA class as foundational maintenance bronchodilation: aclidinium fits as monotherapy in group A, while a LABA+LAMA combination (aclidinium+formoterol: Brimica Genuair, Duaklir Genuair) covers groups B and E. The Cochrane 2018 network meta-analysis (Oba) found no advantage of aclidinium over other long-acting bronchodilators in exacerbations. Marketing as a «newest-generation LAMA with superior efficacy» is not supported.
- ABudesonide/formoterolSecond line · Inhaled corticosteroid (ICS) plus long-acting β2-agonist (LABA) combination with rapid onsetIn COPD, used in patients with frequent exacerbations and blood eosinophils above 300 cells/mcL (GOLD 2024). Dose 320/9 mcg twice daily. Reduces exacerbations by 25% but raises pneumonia risk – benefit outweighs risk only in confirmed eosinophilia or eosinophilic COPD phenotype.
- AFormoterolFirst line · Long-acting selective β2-agonist with rapid onset (rapid-onset LABA)LABA for COPD maintenance. GOLD 2024 and GesEPOC 2024 list formoterol as an option in group B and in LABA+LAMA combinations for frequent exacerbations. Nebulised use (Perforomist, Brovana) is available for patients who cannot manage MDI or dry-powder inhalers.
- ASalbutamol (Albuterol)First line · Short-acting beta-2 adrenergic agonists (SABA)GOLD 2024 recommends salbutamol as a rescue bronchodilator in COPD. Maintenance therapy relies on long-acting bronchodilators (LAMA and/or LABA), while SABA is used on demand for episodes of dyspnea.
- ASalmeterolFirst line · Long-acting selective β2-agonist (LABA, bronchodilator)LABA for COPD maintenance. GOLD 2024 and GesEPOC 2024 list salmeterol as an option in group B (moderate symptoms, few exacerbations) and in LABA+LAMA combinations (Anoro, Ultibro) in group E. In COPD, LABA monotherapy without ICS is acceptable – no excess mortality as seen in asthma.
- ASalmeterol + FluticasoneSecond line · Fixed-dose combination: long-acting beta-2 agonist (LABA) plus inhaled corticosteroid (ICS)COPD with frequent exacerbations (≥2/year or ≥1 with hospitalization) and eosinophils ≥300 cells/µL. Per GOLD 2024, ICS-LABA is added to LAMA or used as part of triple therapy LAMA+LABA+ICS. Dose: 50/500 µg twice daily. Before starting, discuss increased pneumonia risk (NNH ~14 per year). Reassess at 12 months.
- ATiotropiumFirst line · Long-acting muscarinic antagonist for inhalation (LAMA)Tiotropium is a first-line LAMA for COPD maintenance. GOLD 2024 and GesEPOC 2024 recommend LAMA monotherapy in group B; with frequent exacerbations a LABA is added (LABA+LAMA: Spiolto, Anoro) or triple therapy ICS+LABA+LAMA (Trelegy, Trimbow). The Cochrane 2018 network meta-analysis (Oba) showed comparable efficacy with aclidinium and umeclidinium for exacerbations and mortality.
- BBudesonideCase-by-case decision · Inhaled corticosteroids (ICS)Per GOLD 2024, ICS in COPD is not for everyone. Triple therapy (ICS + LABA + LAMA) is indicated with frequent exacerbations or eosinophilia. In patients without these criteria, ICS confer no benefit and increase pneumonia risk – dual bronchodilation (LABA + LAMA) is preferred.
- BFluticasoneSecond line · Inhaled and intranasal corticosteroidCOPD with frequent exacerbations (≥2/year or ≥1 with hospitalization) and eosinophils ≥300 cells/µL. Per GOLD 2024, an inhaled corticosteroid is added to LABA or LABA + LAMA – monotherapy is not indicated. Fluticasone propionate dose: 500 µg twice daily. Increased pneumonia risk in COPD – discuss with the patient and reassess at 12 months.
- BFluticasone propionateCase-by-case decision · Inhaled corticosteroids (ICS)Per GOLD 2024, ICS in COPD is reserved for subgroups with frequent exacerbations or eosinophilia. The TORCH trial with fluticasone/salmeterol showed reduced exacerbations and potentially reduced mortality but raised pneumonia risk. In patients without ICS indications, dual bronchodilation is preferred.
- BIpratropium bromideSecond line · Short-acting muscarinic antagonist for inhalation (SAMA)Ipratropium as COPD maintenance is outdated. GOLD 2024 and GesEPOC 2024 put LAMAs (tiotropium, aclidinium, umeclidinium, glycopyrronium) as first line: once-daily, better tolerated, superior exacerbation reduction. Ipratropium 3–4 times daily remains an option only when a LAMA cannot be prescribed (cost, availability, intolerance). Continuing it because «mother used to take it» or «it is cheaper» without reviewing symptom control reflects an outdated approach.
- BTheophyllineThird line · MethylxanthineIn chronic obstructive pulmonary disease, theophylline is considered reserve therapy at GOLD stages 3–4 when long-acting bronchodilators (LABA, LAMA) and inhaled corticosteroids provide inadequate control. GOLD 2024 does not recommend theophylline as first- or second-line therapy because of an unfavorable side-effect profile and narrow therapeutic window. A possible additional anti-inflammatory effect at low doses in severe COPD.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit