2023 Canadian Thoracic Society Guideline on Pharmacotherapy in Patients With Stable COPD.

Chronic obstructive pulmonary disease patient care must include confirming a diagnosis with postbronchodilator spirometry. Because of the clinical heterogeneity and the reality that airflow obstruction assessed by spirometry only partially reflects disease severity, a thorough clinical evaluation of the patient should include assessment of symptom burden and risk of exacerbations that permits the implementation of evidence-informed pharmacologic and nonpharmacologic interventions. This guideline provides recommendations from a comprehensive systematic review with a meta-analysis and expert-informed clinical remarks to optimize maintenance pharmacologic therapy for individuals with stable COPD, and a revised and practical treatment pathway based on new evidence since the 2019 update of the Canadian Thoracic Society (CTS) Guideline. The key clinical questions were developed using the Patients/Population (P), Intervention(s) (I), Comparison/Comparator (C), and Outcome (O) model for three questions that focuses on the outcomes of symptoms (dyspnea)/health status, acute exacerbations, and mortality. The evidence from this systematic review and meta-analysis leads to the recommendation that all symptomatic patients with spirometry-confirmed COPD should receive long-acting bronchodilator maintenance therapy. Those with moderate to severe dyspnea (modified Medical Research Council ≥ 2) and/or impaired health status (COPD Assessment Test ≥ 10) and a low risk of exacerbations should receive combination therapy with a long-acting muscarinic antagonist/long-acting ẞ2-agonist (LAMA/LABA). For those with a moderate/severe dyspnea and/or impaired health status and a high risk of exacerbations should be prescribed triple combination therapy (LAMA/LABA/inhaled corticosteroids) azithromycin, roflumilast or N-acetylcysteine is recommended for specific populations; a recommendation against the use of theophylline, maintenance systemic oral corticosteroids such as prednisone and inhaled corticosteroid monotherapy is made for all COPD patients.
Competing Interests: Financial/Nonfinancial Disclosures Members of the CTS COPD Guideline Panel declared potential conflicts of interest at the time of appointment, and these were updated throughout the process in accordance with the CTS Conflict of Interest Disclosure Policy. J. B. reports grants from McGill University, the McGill University Health Centre Foundation, the Canadian Institute Health Research, Grifols, Novartis, Sanofi, and the Respiratory Health Network of the Fonds de la recherche en santé du Québec; grants and personal fees from Astra Zeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, and Trudell Canada Ltd; and personal fees from Pfizer Canada Ltd, and COVIS Pharma Canada Ltd, outside the submitted work. M. B. reports personal fees and grants outside the submitted work from AstraZeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, Novartis, Sanofi-Genzyme, the Canadian Institute Health Research, CHEST, The Lung Association of Alberta, The University of Alberta Hospital Foundation, Alberta Innovates Health Solutions, Valeo, and Covis. P. H. reports grants from the Canadian Institute Health Research, the Lung Association of Nova Scotia, the Nova Scotia Health Authority Research Fund, Astra Zeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, Cyclomedica, Grifols, Respivant, and Vertex; and personal fees from Astra Zeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, Janssen, Merck, Novartis, Sanofi-Aventis, and Trudell, outside the submitted work. S. D. A. receives grants from CIHR. He has received speaking honoraria or has participated on advisory boards for GSK, AZ, Chiesi, and Sanofi. M-F. B. reports grants and personal fees from the Cercle du doyen (Faculté de pharmacie, Université de Montréal) and Astra Zeneca Canada Ltd. A. D. reports receiving research, consulting and lecturing fees from GlaxoSmithkline, Sepracor, Schering Plough, Altana, Methapharma, AstraZeneca, ONO pharma, Merck Canada, Forest Laboratories, Novartis Canada/USA, Boehringer Ingelheim (Canada) Ltd, Pfizer Canada, SkyePharma, and KOS Pharmaceuticals and Almirall, Sanofigenzyme and TEVA Canada, Valeopharma Canada. F. M. reports grants from AstraZeneca and GlaxoSmithKline, Boehringer Ingelheim, GSK, Sanofi, and Novartis, and personal fees for serving on speaker bureaus and consultation panels from GlaxoSmithKline, Grifols, and Novartis. He is financially involved with Oxynov, a company which is developing an oxygen delivery system. S. M. reports grants outside the submitted work from Canadian Institute of Health Research and Canadian Lung Association in partnership with Boehringer Ingelheim Canada Ltd and Astra Zeneca Canada Ltd. E. P. reports personal fees from COVIS Pharma, Sanofi Genzyme, Boehringer Ingelheim Canada Ltd, Astra Zeneca Canada Ltd, GlaxoSmithKline Canada Ltd, and Novartis; and grants from the Canadian Institute Health Research, the Saskatchewan Research Foundation, the Respiratory Research Centre, and Astra Zeneca Canada Ltd, outside the submitted work. D. D. S. reports personal fees from GlaxoSmithKline Canada Ltd, Boehringer Ingelheim, and AstraZeneca outside of the submitted work. J. W. reports personal fees from GlaxoSmithKline Canada Ltd and Astra Zeneca Canada Ltd and a grant from Fisher & Paykel, outside the submitted work. B. L. W. reports personal fees from AstraZeneca Canada Ltd, Boehringer Ingelheim Canada Ltd, GlaxoSmithKline Canada Ltd, Novartis, Sanofi-Genzyme and Covis Pharma Canada, outside of the submitted work. D. D. M. reports consultancy work with Alberta Health Services, Health Canada, Lung Saskatchewan, Ontario Ministry of Health and Long-Term Care, Saskatchewan Health Authority, Saskatchewan Ministry of Health, Yukon Health and Social Services; reports grants (managed by University of Saskatchewan) from AstraZeneca, Boehringer Ingelheim, Canadian Institute of Health Research, GlaxoSmithKline, Grifols Therapeutics, Lung Saskatchewan, Novartis, Sanofi-Aventis, Saskatchewan Health Research Foundation, Syneos Health, Schering-Plough; employee/roles with University of Saskatchewan, Deputy Editor - CHEST Journal, Board Member - Saskatchewan Health Research Foundation; outside the submitted work. None declared (A. L., A. V. D., S. B. K., J. D. M.).
(Copyright © 2023 Canadian Thoracic Society and American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)