I use triple therapy on most of my patients with shortness of breath.

Non-Pharmacologic Therapy: The GOLD guidelines recommend smoking cessation, flu and pneumococcal vaccinations for patients with COPD in Groups A through D. Vaccinations are one way to reduce exacerbations, which are known to cause a more rapid decline in lung function, increased morbidity and mortality.
Staging COPD : Group A to D with spirometry, oxygen use and symptoms
Prescription options include long-acting inhalers that are used on a regular basis to control COPD. Short-acting inhalers are used whenever symptoms flare up as well as anti-inflammatory

As an Emergency Medicine physician, I treat COPD and ACOS patients who are experiencing acute flare-ups and I prefer to add a separate steroid inhaler like mometasone and a 5-7 days course of prednisone(40mg a day) to pts who are already on a LABA/LAMA inhaler. I will also add a 5 day course of Zithromax if they have a productive cough. This way, the steroid component of the treatment can removed later if no longer needed after the flare-up resolves. John

The Gold Guidelines are very helpful. We must not neglect to bring up the cost of these medications. Some patients are simply unable to afford these inhaled therapies. We do use patient assistance lines, but at times we are unable to follow the guidelines due to the high expense of these medications.

Treatment recommendations by GOLD COPD guidelines is based on severity. Severity is determined by COPD exacerbations per year, FEV1, mMRC scale/CAT. Therapy can be initiated with fever than two exacerbations with no hospitalizations and mMRC 0-1 or CAT <10. I use triple therapy for my patients who fail dual therapy.

Updated GOLD guidelines are effective in limiting the use of SABA and OCS as mainstays of COPD therapy, as well as limiting the unnecessary use of triple LABA/LAMA/OCS to limit overall medication exposure to our patients.

GOLD guidelines have been the standard in copd management. Most patients were/are smokers, so discussing smoking cessation is also important.

The recommended initial treatment for mild exacerbations is the use of short-acting beta2-agonists, with or without short-acting anticholinergics. In moderate-to-severe exacerbations, in addition to the SABA, systemic corticosteroids and antibiotics may also be used for no more than 5 to 7 days to improve FEV1, shorten recovery time, reduce the risk of early relapse, and shorten duration of hospitalization. The guidelines recommend continuing the use of long-acting bronchodilators throughout the exacerbation or to start these medications as soon as possible before discharge.

There is a push for using triple therapy out of the gate. I use it once there is dual therapy failure or an exacerbation or if there is eosinophilia. Following spirometry, preventing exacerbations, and compliance are key.

Use of the GOLD guidelines have improved treatment and reduced Steroid use.

When to recommend treatment: when patients have symptoms of COPD (eg dyspnea, chronic cough, sputum production) and/or history of exacerbations. The choice of initial therapy is guided by the severity of symptoms and the risk of future exacerbations.
Impact on Triple Therapy Use: the guidelines underscore the importance of de-escalation strategies in patients on triple therapy when possible, to minimize the risk of adverse effects, such as pneumonia. This approach encourages regular reassessment of the patient’s condition to determine if all components of triple therapy are still needed.

I would pick treatment based on daily patient symptoms and frequency of eosinophil count helps too

The GOLD guidelines recommend treating COPD based on symptom severity and exacerbation risk assessed through spirometry. Treatment begins with short-acting bronchodilators for mild symptoms (Group A), progressing to long-acting bronchodilators for moderate symptoms (Group B). For patients at high risk of exacerbations, combination therapies like LABA/LAMA are preferred (Groups C and D). Triple therapy (ICS/LABA/LAMA) is reserved for severe cases with frequent exacerbations (Group D), reflecting a personalized approach based on individual patient needs and response to initial therapies.

I use the GOLD guidelines to help with step care and I prefer to have good PFT data to assist. Using the guidelines does help limit the use of excess steroids, but the patients with more severe symptoms often warrant using the heavier meds and then backing back down the steps so to speak.

I would combine patient symptoms with findings on physical exam and, preferably, confirmatory spirometry.

i use the gold approach to determine initial and maintenance therapy for my COPD patients. It is a helpful guide for primary care physicians for add on LAMA, LABA plus ICS, to include triple therapy preemptively.

GOLD guidelines have helped tremendously to guide the treatment for COPD patients and minimize the use of steroids

The GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines provide a framework for the diagnosis, management, and prevention of Chronic Obstructive Pulmonary Disease (COPD). According to GOLD guidelines, treatment for patients with COPD is recommended based on the severity of symptoms and the risk of exacerbations. The GOLD classification system categorizes patients into four groups (A, B, C, D) based on their symptoms, exacerbation history, and spirometry results.

Treatment recommendations vary depending on the GOLD group:

Group A: Patients have low symptoms and a low risk of exacerbations. Treatment typically starts with short-acting bronchodilators (such as short-acting beta-agonists or anticholinergics) as needed.

Group B: Patients have higher symptoms but still a low risk of exacerbations. Long-acting bronchodilators (such as long-acting beta-agonists or long-acting anticholinergics) are recommended as initial therapy.

Group C: Patients have low symptoms but a high risk of exacerbations. Inhaled corticosteroids (ICS) in combination with a long-acting bronchodilator are recommended.

Group D: Patients have both high symptoms and a high risk of exacerbations. Treatment options include dual bronchodilation (long-acting beta-agonist plus long-acting anticholinergic) or triple therapy (ICS plus long-acting beta-agonist plus long-acting anticholinergic).

Triple therapy (ICS/LABA/LAMA) has become increasingly recognized as an effective treatment option for patients with COPD, especially those in Group D who have persistent symptoms and frequent exacerbations despite dual bronchodilation. The GOLD guidelines have played a significant role in shaping the use of triple therapy by providing clear recommendations for its use in specific patient populations.

Healthcare providers may consider triple therapy earlier in the treatment algorithm for patients with severe or very severe COPD who remain symptomatic or at high risk of exacerbations despite initial therapy with dual bronchodilation. However, the decision to initiate triple therapy should always be individualized based on the patient's clinical characteristics, preferences, and response to previous treatments.

Treat any patient that has had an exacerbation , needs their albuterol rescue inhaler more than twice a week, or any limitations in quality of life. The guidelines provide guidance in a stepwise approach using a LAMA/LABA then triple therapy if patients have an exacerbation or their COPD worsens.

Starting with antimuscarinic therapy along with rescue therapy has histically been effective and with few side effects in my experience. The all in one triple therapy option for symptomsbreakthrough has been the new standard for my patients with consistent efficacy and still few side effects.

GOLD guidelines have helped tremendously to guide the treatment for COPD patients and helps us to use guidelines in most effective way.

I feel the GOLD guidelines are extremely useful for guiding therapy, but of course should be individually tailored and potentially modified as needed based on the clinical scenario and each unique patient's attributes, always factoring in other coexisting patient morbidities.

I use the GOLD guidelines to help determine a step-wise approach to managing COPD including when to utilize triple therapy.
They are useful in helping validate the decisions made to treat from both a risk and symptom management standpoint.

LABA + LAMA is the preferred choice for initial therapy except in mild cases. Unless blood eos > 300, ICS use is not encouraged. Inhaler technique is very important and frequently overlooked. Often changing to a nebulizer is a good option when patients are unable to use dry powder inhalers.

The GOLD guidelines are a good framework for initiating and advancing treatment. Typically I use a LABA/LAMA combination in people who have moderate COPD and under 2 exacerbations in the past 1-2 years with eosinophils under 300/ul. If the eosinophils are high I will start with triple therapy. If LAMA/LABAdoes not have the desired effect on QOL or exacerbations I will add an ICS regardless of eosinophil count. There are also other additional treatments including adding daily or intermittent azithromycin, theophylline (yes it does still work for some), adding nebulized ipratropium and/or albuterol, and even using mucolytics. These are not in the guidelines but are low cost and work well for some. There are other approaches but I’m out of time. Most important: get smokers to stop!

I always follow the GOLD guidelines in the management of my COPD patients. The goal is always to improve outcomes and mitigate risk. Triple therapy is key in so many patients .

Treatment is usually initiated when patients experience persistent symptoms or exacerbations despite bronchodilator use. Triple therapy, which combines an inhaled corticosteroid (ICS), a long-acting beta-agonist (LABA), and a long-acting muscarinic antagonist (LAMA), is recommended as a treatment option in these cases to improve symptom control and reduce exacerbation risk.

The GOLD guidelines have helped to provide an evidence based approach to treatment of COPD.

I agree with the guidelines and treat with triple therapy often including counts above 300, smokers and moderate to severe patients

Updated GOLD guidelines have made the criteria for diagnosis of COPD more simple: progressively worsening dyspnea that is worse with exercise, recurrent wheezing, chronic cough, recurrent LRI's and/or risk factors including smoking hx, FHx, occupational exposures, etc.

Once the diagnosis is made, LAMA and/or LABA is the recommended initial therapy. GOLD guidelines have been impactful in my treatment algorithm because it gives clear indicators of when triple therapy should be initiated: eosinophilia >300 or progression/exacerbations despite LAMA/LABA use.

i use triple therapy on those COPD PATIENTS who refuse to quit smoking and elevated eosinophils above 300

Updated guidelines really a bit more simple. For mildly symptomatic disease usually start single agent typically LAMA & escalate. ICS if they seem to have reactive airway process in addition, otherwise typically wait until more symptomatic despite LABA/LAMA or exacerbations. Unfortunately limited MOA options otherwise.

The new gold guidelines have streamlines my prescribing for triple therapy. It's helped to identify who really needs triple therapy as opposed to those who need a llama/laba. I've been using exacerbations as well as as eosinophilia as criteria for whether to add a corticosteroids or not.

I think the data is strong that LABA LAMA is better than LAMA alone and that addition of ICS may help further. It would be nice if there were more head to head data among the triple inhalers. There may be a difference in pneumonia risk among the different ICS. Also insurance companies and pharmacy benefits managers frequently cut deals and force us to change inhalers based on price year to year, even in stable patients. That's not right but patients often don't have a choice. It seems like they are pushing biologics now in the asthma COPD overlap and trying to determine who benefits most from them is a challenge.

As a Pulmonologist, by virtue of selection bias based on the overall cohort that gets referred, the harder question is who does NOT benefit from maintenance therapy. As such almost all patients who present are category B or E. Most recently the GOLD guidelines provided better clarity on ICS use, and other options for AECOPD reduction.

Many patients are overusing SABA due to immediate results. Patients with proven radiological findings of COPD or exacerbations resulting in ER / hospital visits as well as office visits would benefit from LABA / LAMA combination. PFTs also help to guide treatment. However, many patients that have utilized oral steroids in the past, do not get sustained benefits from dual therapy and benefit from triple therapy treatment. Also some patients on prior ICS / LABA therapy, sometimes require the ICS when switched to LABA/LAMA therapy. Utilization of respiratory & lab testing as well as patient input is what guides therapy choices.

persisted smokers with copd have more bouts of sickness and sob ,so i start them on triple therapy

Recent GOLD guideline has provided stepwise approach for patients with COPD in an evidence-based matter and has changed my practice pattern for prescribing LABA/LAMA vs. LABA/ICS vc. LABA/LAMA/ICS.

Persistent symptoms, or exacerbations, while using LAMA/LABA are indications to change to triple therapy. This is in agreement with the treatment protocol we have been utilizing.

Persistent symptoms, or exacerbations, while using LAMA/LABA are indications to change to triple therapy. This is in agreement with the treatment protocol we have been utilizing.

When the patient is having symptoms. SOB, cough, etc. GOLD guidelines has justified what I was already doing for a lot of patient regarding triple therapy

Treatment of COPD should be based on both spirometry and patient symptoms since the goal of treatment is to reduce risk AND reduce symptoms. I have attempted to transition patients who do not meet GOLD guidelines for triple therapy to a LABA/LAMA

Many patients are overusing SABA due to immediate results. Patients with proven radiological findings of COPD or exacerbations resulting in ER / hospital visits as well as office visits would benefit from LABA / LAMA combination. PFTs also help to guide treatment. However, many patients that have utilized oral steroids in the past, do not get sustained benefits from dual therapy and benefit from triple therapy treatment. Also some patients on prior ICS / LABA therapy, sometimes require the ICS when switched to LABA/LAMA therapy. Utilization of respiratory & lab testing as well as patient input is what guides therapy choices.

COPD should be classified based on Spiromerty for treatment as LAMA along is the preferred therapy for the asymptomatic pts diagnosed on Imaging and spirometry as the progression of the disease takes place based on the symptoms of cough and SOB addition of the LABA is warranted however any exacerbation neccisates the additon of the ICS and theavailability of the tripple therpay in one device has changed the landscape of COPD therapy and the threshold of using it is much lower than ever ! Tripple therapy is by far the most effective treatment to prevent the progression of COPD and with good results What is important in management of COPD is risk factor modification and to screen for alpha 1 trypsin deficiency too to identify pts with rapid progression and these pts early use of tripple therapy is warranted . GOLD 2024 do emphasize on early than later use of tripple therapy and following the same protocol in my practice with good results and compliance