Chronic Obstructive Pulmonary Disease (COPD)
The pathways in this section refer to the GOLD Guidelines 2024. This means that pathways (GOLD A, B, E)) are not a stepwise progression, but intended as a guide for initiation of the pharmacological management of COPD according to the individual patient assessment of symptoms and exacerbation risk following the ABE scheme. Following reclassification of GOLD guidelines in 2023, patients historically prescribed monotherapy bronchodilators should be reviewed accordingly.
As part of NHS Scotland’s commitment to greener health care, the environmental impact of inhalers has been examined. The majority of carbon emissions from inhalers come from the propellants in pressurised metered-dose inhalers (pMDIs), which currently account for 66.6% of all inhaler device types prescribed in NHS Scotland. The East Region Formulary encourages prescribers to have a full discussion of inhaler choices with patients, taking into account environmental impact, inhaler technique and patient factors and when clinically appropriate to prescribe a dry powder inhaler (DPI) as first choice. Further information can be found through PrescQIPP.
A diagnosis of COPD must be made using spirometry. The presence of non-fully reversible airflow limitation (i.e., FEV1/FVC<0.7 post-bronchodilation) measured by spirometry is mandatory to establish the diagnosis of COPD.
Refer to NICE CKS: Chronic obstructive pulmonary disease for prescribing information on all medicines.
In NHS Lothian refer to Lothian Respiratory resources for Healthcare professionals for inhaler technique, inhaler training guide and inhaled therapies guidance poster.
In NHS Fife refer to Guidance on Inhaled Therapies: COPD.
GOLD COPD NICE CKS: Chronic obstructive pulmonary disease
Bronchodilator options for 0 or 1 moderate exacerbations (no hospital admissions) and mMRC 0-1, CAT <10. Dry Powder Inhaler choice – Easyhaler, or Salbutamol Metered-Dose Inhaler.
Initially 100–200micrograms, increased if necessary to 400micrograms; maximum 800micrograms per day.
100-200micrograms, up to 4 times a day for persistent symptoms.
LAMA/LABA (Long Acting Muscarinic Antagonist/Long Acting Beta2 Agonist) options.
LAMA/LABA Dry Powder Inhaler – Anoro Ellipta.
One inhalation once daily (each inhalation is equivalent to 55micrograms umeclidinium and 22micrograms of vilanterol).
LAMA/LABA soft-mist inhaler – Spiolto Respimat.
Two puffs one daily.
Two puffs once daily.
LAMA/LABA Metered-dose Inhaler– Bevespi Aerosphere.
2 inhalations twice daily.
Dry Powder Inhaler – Bricanyl Turbohaler.
1 inhalation (500micrograms) up to 4 times daily, for persistent symptoms.
LAMA/LABA (Long Acting Muscarinic Antagonist/Long Acting Beta2 Agonist) options).
LAMA/LABA Dry Powder Inhaler – Anoro Ellipta.
One inhalation once daily (each inhalation is equivalent to 55micrograms umeclidinium and 22micrograms of vilanterol).
LAMA/LABA soft-mist inhaler – Spiolto Respimat.
Two puffs once daily.
Two puffs once daily.
LAMA/LABA Metered-dose Inhaler– Bevespi Aerosphere.
2 inhalations twice daily.
Prescribing Notes:
- There is virtually no difference in efficacy between salbutamol and terbutaline; currently salbutamol is less expensive and available in a wider range of devices.
- Before prescribing a Respimat device please ensure patient is able to load device and activate.
- Long-acting bronchodilator therapy is the preferred choice except in patients with very occasional breathlessness
- Long-acting monotherapy with a LABA or LAMA can be considered due to patient preference, where a MDI is required, or where an individual component of the combination therapy is contra-indicated or not tolerated due to side effects
- Where a patient derives additional benefit from as needed SABA this should be continued along with long-acting bronchodilation therapy
History Notes
25/11/2024
Addition of Bevespi SMC2652, ERWG Nov 24.
04/09/2024
Updated prescribing information, ERWG July 2024.
09/04/2024
GOLD guidelines updated 2023, ERFC February 2024.
16/02/2022
East Region Formulary content agreed.
LAMA/LABA (Long Acting Muscarinic Antagonist/Long Acting Beta2 Agonist) options for 0 or 1 moderate exacerbations (no hospital admissions) and mMRC ≥ 2, CAT ≥10.
LAMA/LABA Dry Powder Inhaler – Anoro Ellipta.
One inhalation once daily (each inhalation is equivalent to 55micrograms umeclidinium and 22micrograms of vilanterol).
LAMA/LABA soft-mist inhaler – Spiolto Respimat.
Two puffs once daily.
Two puffs once daily.
Prescribing Notes:
- Before prescribing a Respimat device please ensure patient is able to load device and activate.
- For patients with persistent breathlessness or exercise limitation on bronchodilator monotherapy, the use of LAMA/LABA is recommended.
- Following GOLD guideline reclassification, it is recommended that patients on historical monotherapy should be reviewed as appropriate.
History Notes
04/09/2024
Updated prescribing notes, ERWG July 2024
09/04/2024
GOLD guidelines updated 2023 – content agreed at ERFC February 2024.
16/02/2022
East Region Formulary content agreed.
LAMA/LABA (Long Acting Muscarinic Antagonist/Long Acting Beta2 Agonist) options for ≥2 moderate exacerbations (or ≥1 leading to hospital admission)
Dry Powder Inhaler – Anoro Ellipta
One inhalation once daily (each inhalation is equivalent to 55micrograms umeclidinium and 22micrograms of vilanterol).
LAMA/LABA soft-mist inhaler – Spiolto Respimat.
Two puffs once daily.
Two puffs once daily.
LABA/LAMA/ICS (Long Acting Beta2 Agonist/ Long Acting Muscarinic Antagonist/ Inhaled Corticosteroid Combination) options if blood eosinophils ≥300 cells/microlitre.
Dry Powder Inhaler – Trelegy Ellipta.
One inhalation daily, dose should be taken at the same time each day.
LABA/LAMA/ICS options: Metered-Dose Inhaler – Trimbow or Dry Powder Inhaler – Trimbow NEXThaler.
Two inhalations twice daily.
Two inhalations twice daily.
LABA/LAMA/ICS options: Metered-Dose Inhaler Trixeo Aerosphere inhaler.
Two inhalations twice daily.
Prescribing Notes:
- Before prescribing a Respimat device please ensure patient is able to load device and activate.
- Combination products can be a cost effective alternative to the individual products and are more convenient to use. Choice will depend on the selected inhaled steroid and inhaler technique.
- LAMAs must not be given in combination with ipratropium.
- Use of Trimbow is restricted to use in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid and a long acting beta2-agonist, with FEV1 (% predicted) is less than 50%.
- Use of Trelegy is restricted to use in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid and a long acting beta2-agonist, with FEV1 (% predicted) is less than 50%.
- Use of Trixeo is restricted to use in adult patients with moderate to severe COPD who are not adequately treated by a combination of an inhaled corticosteroid and a long acting beta2-agonist, or combination of a long-acting beta2-agonist and a long-acting muscarinic antagonist, with FEV1 (% predicted) is less than 50%.
- If patients with COPD have concomitant asthma, they should be treated like patients with asthma. Refer to Asthma pathway. Under these circumstances the use of an ICS is mandatory.
- For patients with persistent breathlessness on bronchodilator monotherapy, escalation to LABA+LAMA is recommended.
- Blood eosinophil counts may identify patients with a greater likelihood of a beneficial response to ICS. For patients who develop exacerbations with a blood eosinophil count ≥ 300 cells/µL, escalation to LABA+LAMA+ICS may be considered.
- Withdrawing ICS should be considered if pneumonia or other considerable side-effects develop.
History Notes
04/09/2024
Updated prescribing notes, ERWG July 2024
09/04/2024
GOLD guidelines updated 2023 – content agreed at ERFC February 2024.
10/10/2023
Luforbec MDI replaces Fostair MDI, ERFC June 2023.
29/06/2023
Trixeo Aerosphere added and prescribing notes updated. ERWG May 2023.
06/10/2022
Added Trimbow NEXThaler ERFC May 22.
Specialist initiation following investigations in secondary care.
Dose as per specialist.
Prescribing Notes:
- Prescribing of azithromycin should be on the advice of a respiratory specialist, following sensitivities and investigations in secondary care.
History Notes
09/04/2024
GOLD guidelines updated 2023 – content agreed at ERFC February 2024
10/10/2023
Luforbec MDI replaces Fostair MDI, ERFC June 2023.
29/06/2023
Trixeo Aerosphere added and prescribing notes updated. ERWG May 2023.
06/10/2022
Added Trimbow NEXThaler ERFC May 22.
16/02/2022
East Region Formulary content agreed.
One tablet, once daily, dispersed in water.
Two capsules three times a day, can reduce to two capsules twice daily if response satisfactory.
Prescribing Notes:
- A 4-week trial of a mucolytic agent should be considered in COPD patients chronically troubled by sputum production. Only continue if symptoms improve.
History Notes
04/09/2024
Updated prescribing information, ERWG July 2024.
16/02/2022
East Region Formulary content agreed.
Prednisolone with or without an antibiotic (amoxicillin or doxycycline).
30mg should be prescribed for 5 days. No evidence to support the weaning of prednisolone over a longer period following a 5 day course
500mg every 8 hours for 5 days.
500mg every 8 hours for 5 days.
200mg on day 1, then 100mg daily for 5 days treatment in total.
Consider an alternative antibiotic (amoxicillin or doxycycline) that wasn’t used as first choice.
Prescribing Notes:
- The vast majority of respiratory tract illness is self-limiting and it is recommended that the term “infection” is avoided. Purulent sputum alone is not a marker for antibiotic treatment.
- Oral cephalosporins are not a suitable choice as they do not penetrate lung tissue.
- Antibiotics are only indicated in acute exacerbations of COPD when purulent sputum and increased breathlessness and/or increased sputum volume are present.
- Risk factors for antibiotic resistant organisms include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in the last three months. Consider sending a sputum sample +/- chest X-ray to assess if consolidation present.
- Co-trimoxazole may be considered for use, particularly in individuals who have received multiple courses of antibiotics, the elderly and those at risk of Clostridium difficile infection, and have persistent symptoms of infection despite first line antibiotics. Send sputum for culture and consider a CXR.
- Patients on high doses of steroids who receive more than three to four courses of oral steroids per year should be considered for bone protection. See osteoporosis recommendations in the Endocrine chapter of the formulary.
- Where laboratory susceptibility reports recommend that increased dosing is required for specific antimicrobials in relation to organism susceptibility, please refer to local ‘Adult High Dose Antimicrobial Regimens Based on Susceptibility Reporting’ guidelines.
History Notes
25/11/2024
New content agreed - ERWG November 2024.
09/04/2024
GOLD guidelines updated 2023 – content agreed at ERFC February 2024.
16/02/2022
Info note at second line improved following feedback from Respiratory Chapter Expert Working Group.
15/12/2021
East Region Formulary content agreed.
Prescribing Notes:
- Best practice is to prescribe all inhalers by brand name (except salbutamol) and device type.
- Changing the type of inhaler device may impact the effectiveness of therapy and the incidence of adverse effects. There are new versions of existing combination inhalers coming on to the market. Take care to ensure the intended product is prescribed and dispensed.
- Assessment of a patient’s inhaler technique is required before an inhaler is prescribed as this will determine the choice of product. Information on assessing inhaler technique and counselling on the correct method can be found at the PrescQIPP website or the My Lungs My Life website. The individual forms can be printed out for patient use.
- Older patients may have difficulty using any inhaler device due to reduced hand strength, poor inspiratory effort, or confusion. Individual assessment is required.
- All inhalers have different ‘in use’ expiry, this can lead to unintended wastage. Ensure patients are given adequate advice on effective use of the device. For example, an inhaler with an in use expiry of 6 weeks: one inhaler lasts 1 month with regular use. If 2 inhalers are prescribed and dispensed and both opened at the same time, they will both expire 6 weeks later, but if opened one at a time they would have lasted 8 weeks.
- Inhaler-induced cough by MDI may be alleviated by use of a spacer or change of device.
- It is essential to specify inhaler device, strength and dose.
- Not all spacers are compatible with all inhalers; users should seek advice from their local pharmacist regarding the appropriate spacer to be used.
History Notes
16/02/2022
East Region Formulary content agreed.
2.5–5mg up to 4 times daily or more frequently. In severe cases 5mg, repeat every 20–30 minutes or when required.
2.5–5mg up to 4 times daily or more frequently. In severe cases 5mg, repeat every 20–30 minutes or when required.
2.5–5mg up to 4 times daily or more frequently. In severe cases 5mg, repeat every 20–30 minutes or when required.
500micrograms as required; maximum 2mg per day.
500micrograms as required; maximum 2mg per day.
Prescribing Notes:
- Nebulisers are not currently prescribable in general practice; patients should be referred for respiratory assessment and if suitable they will be leased a machine. A spacer should be tried before considering a nebuliser.
- All nebulisers should be serviced regularly. However, difficulties are often encountered in the servicing of privately owned nebulisers. Patients should be discouraged from buying a nebuliser.
- Ipatropium nebuliser should not be given with a LAMA.
- Patients with acute exacerbation of COPD rarely require doses higher than 2.5mg salbutamol via nebulisers. Higher doses may be required in asthma where there is a dose related response.
History Notes
09/04/2024
GOLD guidelines updated 2023 – content agreed at ERFC February 2024.
16/02/2022
East Region Formulary content agreed.
Nebulisers should only be used in patients with an FEV1<50% and on maximum inhaled therapy under care of a respiratory specialist.
2.5–5mg up to 4 times daily or more frequently. In severe cases 5mg, repeat every 20–30 minutes or when required.
2.5–5mg up to 4 times daily or more frequently. In severe cases 5mg, repeat every 20–30 minutes or when required.
2.5–5mg up to 4 times daily or more frequently. In severe cases 5mg, repeat every 20–30 minutes or when required.
500micrograms as required; maximum 2mg per day.
500micrograms as required; maximum 2mg per day.
Prescribing Notes:
- Nebulisers are not currently prescribable in general practice; patients should be referred for respiratory assessment and if suitable they will be leased a machine. A spacer should be tried before considering a nebuliser.
- All nebulisers should be serviced regularly. However, difficulties are often encountered in the servicing of privately owned nebulisers. Patients should be discouraged from buying a nebuliser.
- Ipatropium nebuliser should not be given with a LAMA.
- Patients with acute exacerbation of COPD rarely require doses higher than 2.5mg salbutamol via nebulisers. Higher doses may be required in asthma where there is a dose related response.
History Notes
09/04/2024
GOLD guidelines updated 2023, ERFC February 2024.
16/02/2022
East Region Formulary content agreed.
For use with pressurised inhalers.
For use with pressurised inhalers.
For use with pressurised inhalers.
For use with pressurised inhalers.
Prescribing Notes:
- A poster has been developed to provide guidance on selecting the correct AeroChamber Plus Flow-Vu Anti-Static valved holding chamber.
- Local advice is that patients should inhale from the spacer device using a single breath with 5-10 second breath hold.
- Spacers should be cleaned no more than weekly with water and washing-up liquid, or put in a dishwasher, and allowed to air dry. More frequent cleaning affects their performance due to build-up of static.
- AeroChamber Plus Flow-Vu and Volumatic should be replaced every 12 months following regular use.
History Notes
16/02/2022
East Region Formulary content agreed.