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Chronic obstructive pulmonary disease (COPD) is a main cause of death due to interplaying factors, including comorbidities that interfere with symptoms and response to therapy. It is now admitted that COPD management should be based on clinical symptoms and health status and should consider the heterogeneity of patients’ phenotypes and treatable traits. This precision medicine approach involves a regular assessment of the patient's status and of the expected benefits and risks of therapy. The cornerstone of COPD pharmacological therapy is inhaled long-acting bronchodilation. In patients with persistent or worsened symptoms, factors likely to interfere with treatment efficacy include the patient's non-adherence to therapy, treatment preference, inhaler misuse and/or comorbidities, which should be systematically investigated before escalation is considered. Several comorbidities are known to impact symptoms, physical and social activity and lung function. The possible long-term side-effects of inhaled corticosteroids contrasting with their over-prescription in COPD patients justify the regular assessment of their benefits and risks, and de-escalation under close monitoring after a sufficient period of stability is to be considered. While commonly used in clinical trials, the relevance of routine blood eosinophil counts to guide therapy adjustment is not fully clear. Patients’ characteristics, which define phenotypes and treatable traits and thus guide therapy, often change during life, forming the basis of the concept of clinical trajectory. The application of individual trajectory-based management of COPD in clinical practice therefore implies that the benefit:risk ratio is regularly reviewed according to the evolution of the patient's traits over time to allow optimised therapy adjustments.

Chronic obstructive pulmonary disease (COPD) is a main cause of death due to interplaying factors, including comorbidities that interfere with symptoms and response to therapy. It is now admitted that COPD management should be based on clinical symptoms and health status and should consider the heterogeneity of patients' phenotypes and treatable traits. This precision medicine approach involves a regular assessment of the patient's status and of the expected benefits and risks of therapy. The cornerstone of COPD pharmacological therapy is inhaled long-acting bronchodilation. In patients with persistent or worsened symptoms, factors likely to interfere with treatment efficacy include the patient's non-adherence to therapy, treatment preference, inhaler misuse and/or comorbidities, which should be systematically investigated before escalation is considered. Several comorbidities are known to impact symptoms, physical and social activity and lung function. The possible long-term side-effects of inhaled corticosteroids contrasting with their over-prescription in COPD patients justify the regular assessment of their benefits and risks, and de-escalation under close monitoring after a sufficient period of stability is to be considered. While commonly used in clinical trials, the relevance of routine blood eosinophil counts to guide therapy adjustment is not fully clear. Patients' characteristics, which define phenotypes and treatable traits and thus guide therapy, often change during life, forming the basis of the concept of clinical trajectory. The application of individual trajectory-based management of COPD in clinical practice therefore implies that the benefit:risk ratio is regularly reviewed according to the evolution of the patient's traits over time to allow optimised therapy adjustments., Competing Interests: Provenance: Submitted article, peer reviewed. Conflict of interest: N. Roche reports medical writing and meeting support from Boehringer Ingelheim during the conduct of the study; grants and personal fees from Boehringer Ingelheim, Pfizer, GSK and Novartis, and personal fees from AstraZeneca, Chiesi, Sanofi, TEVA and Zambon, outside the submitted work. Conflict of interest: P. Devillier reports medical writing and meeting support from Boehringer Ingelheim during the conduct of the study; and personal fees from AstraZeneca, Chiesi, Menarini, GlaxoSmithKline, Mundipharma, Mylan/Meda Pharma, Novartis and Sanofi, outside the submitted work. Conflict of interest: P. Berger reports medical writing and meeting support from Boehringer Ingelheim during the conduct of the study; grants, personal fees from, and being an investigator on clinical trials for GSK, AstraZeneca, Boehringer Ingelheim, Novartis and Chiesi, being an investigator on clinical trials for Almirall, personal fees from and being an investigator on clinical trials Sanofi, personal fees from Circassia, being an investigator on clinical trials for AB Sciences and Amgen, personal fees from Teva, being an investigator on clinical trials for Janssen, grants from Pierre Fabre, and personal fees from Pfizer, outside the submitted work. Conflict of interest: A. Bourdin reports grants, personal fees and nonfinancial support from, and being an investigator on clinical trials for GSK, AstraZeneca and Boehringer Ingelheim; personal fees and nonfinancial support from, and being an investigator on clinical trials for Novartis and Chiesi; nonfinancial support from Teva; personal fees and nonfinancial support from, and being an investigator on clinical trials for Sanofi Regeneron; grants, personal fees and nonfinancial support from, and being an investigator on clinical trials for Actelion/Janssen; being an investigator on clinical trials for United Therapeutics and Pulsar; and personal fees and nonfinancial support from, and being an investigator on clinical trials for Roche, outside the submitted work. Conflict of interest: D. Dusser reports medical writing and meeting support from Boehringer Ingelheim during the conduct of the study; grants, lecture fees and payment for development of educational activities from Boehringer Ingelheim, and medical writing and meeting support, lecture fees, and payment for development of education activities from AstraZeneca, Pfizer, Novartis, Chiesi and Dey Pharma, outside the submitted work. Conflict of interest: J-F. Muir reports medical writing and meeting support from Boehringer Ingelheim during the conduct of the study. Conflict of interest: Y. Martinat reports medical writing and meeting support from Boehringer Ingelheim during the conduct of the study. Conflict of interest: P. Terrioux reports medical writing and meeting support from Boehringer Ingelheim during the conduct of the study; and personal fees from AstraZeneca, Boehringer Ingelheim, GSK, Menarini, Novartis, Vitalaire and Zambon outside the submitted work. Conflict of interest: B. Housset reports medical writing and meeting support from Boehringer Ingelheim during the conduct of the study; and personal fees from Chiesi, GSK, Novartis, Boehringer Ingelheim, Menarini and AstraZeneca outside the submitted work., (Copyright ©The authors 2021.)

The main purpose of this study was to assess whether pharmacological treatments prescribed by respiratory physicians to patients with chronic obstructive pulmonary disease (COPD) were consistent with the guidelines. The treatments prescribed by respiratory physicians to 631 consecutive patients with COPD, compared to 879 asthmatics were prospectively recorded. All subjects underwent peak expiratory flow rate measurement, spirometry and assessment of recent evolution and dyspnoea (visual analogue and Medical Research Council scales). Patients with COPD received more treatments than asthmatics (mean+/-SD: 2.6+/-0.5 versus 2.2+/-0.4, p<0.0001). Treatments administered to patients with COPD were beta2-agonists in 78% (versus 94% in asthmatics), anticholinergic agents (AC) in 56% (versus 16% in asthma), methylxanthines in 31% (versus 15% in asthma) and inhaled corticosteroids in 76% (versus 85% in asthma). Intensity of treatment was influenced by disease severity for all treatments except AC. In conclusion, pharmacological treatment of chronic obstructive pulmonary disease by respiratory physicians is only partially consistent with current guidelines, with a high proportion of inhaled corticosteroid prescriptions and a relative under-use of anticholinergic agents; this most likely reflects the persistent uncertainties of physicians, and emphasizes that more efforts are required to improve implementation of chronic obstructive pulmonary disease guidelines and assess the efficacy and cost-effectiveness of recommended strategies.