Newly diagnosed patients with mild COPD run the risk of being undertreated with only short-acting bronchodilators or overtreated with inhaled corticosteroids. What is the preferred regimen for these patients?

According to the GOLD guidelines, the patient with mild COPD (Group A) should receive bronchodilator therapy—preferably maintenance therapy with a long-acting bronchodilator. While rescue therapy with short-acting bronchodilators provides symptomatic improvement, long-acting bronchodilators provide additional benefits such as improved lung function, reduced exacerbations, and improved quality of life.

When patients are prescribed both rescue and maintenance therapy, long-acting bronchodilators have been shown to reduce the use of short-acting bronchodilators. This is clinically important because overuse of short-acting bronchodilators is associated with increased risk of exacerbations and mortality. Overuse may be a marker of worsening disease, and the increased mortality risk may also be due to cardiovascular side effects.

The GOLD guidelines recommend maintenance therapy for patients with mild COPD. They do not state a preference between long-acting muscarinic antagonists (LAMAs) and long-acting beta 2 agonists (LABAs). However, a recent 2023 study published in Vol 9 Issue 3 of ERJ Open Research by the ERS, found that LAMAs provide greater improvement in tissue oxygenation, COPD Assessment Test score, and St George Respiratory Questionnaire score than LABAs. In addition, LAMAs are associated with a lower incidence of exacerbations and adverse events than LABAs. Based on these findings, LAMAs may be the preferred choice.

What is your preferred regimen for the initial treatment of mild COPD? When would you consider a LAMA vs. a LABA based on the new findings?