![]() ![]() ICS inhaled corticosteroid LABA long-acting beta-2 agonist LAMA long-acting muscarinic antagonist mcg microgram pwd powder. Except where otherwise noted, this work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. The ATS addresses smoking cessation ( ) in a separate guideline.-Michael J. ICS/LABA Combinations Budesonide/formoterol (Symbicort Turbuhaler) 100 mcg/6 mcg 200 mcg/6 mcg: Inhalant pwd (120 doses) 63.7920 82.8960: 0.5316. Show details Table 9 Combination ICS + LABA Inhalers with Equivalent Dosing A approved propellant From: Asthma Regents of the University of Michigan. Only the ATS discusses the use of opioid therapy for refractory dyspnea. All three organizations recommend long-term oxygen therapy in COPD when associated with severe resting hypoxia, and the ATS alone suggests consideration of ambulatory oxygen with severe exertional hypoxia. All three organizations note that exacerbation risk is further reduced by adding an ICS at the cost of increased pneumonia risk. If patients with COPD are symptomatic despite combination LABA/LAMA therapy, adding an inhaled corticosteroid (ICS) can be considered. Based on cost, ease of use, and clinical equivalence, LAMA monotherapy recommended by the VA/DoD may be the best starting point. That said, over the years, Ive been on different doses of ICS and different LAMAs and LABAs. The GOLD does not recommend any treatment order. Personally, I am on triple therapy, ICS, LABA and LAMA. The ATS recommendation is based on a comparison of combination LABA/LAMA therapy with either monotherapy, which overstates the benefits because LABA monotherapy, but not LAMA monotherapy, is inferior to the combination. LABA/LAMA as First-Line Therapy for COPD: A Summary of the Evidence and Guideline Recommendations. Although all three note that combination LABA/LAMA therapy is superior to monotherapy, the ATS recommends combination LABA/LAMA use by all symptomatic patients with COPD, whereas the VA/DoD recommend starting with LAMA monotherapy. Summary effects of LABA/LAMA combination versus comparators on changes in (A). ![]() Department of Defense (VA/DoD) recommendations and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations that were included in the most recent AFP COPD review ( ). Department of Veterans Affairs and the U.S. Background: Triple therapy combinations of a long-acting muscarinic antagonist (LAMA), a long-acting beta 2-agonist (LABA), and an inhaled corticosteroid (ICS) for COPD were studied in randomized trials and observational studies, with variable results. Bafadhel, M, et al Am J Respir Crit Care Med 2012, 186, 48-55. The recommendations by the ATS are similar to those of the U.S. Targeted oral steroid therapy for acute exacerbations of COPD. ![]()
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