Algorithm A2: Pharmacotherapy

Patient with COPD requiring pharmacotherapy [A]
Is patient asymptomatic and FEV1 greater than or equal to 50% of predicted? No medication is indicated Box 3 to box 18
Are symptoms occurring less frequently than daily AND FEV1 is greater than or equal to 50% of predicted? [B] Short-acting inhaled beta2-agonist (2-4 puffs prn-up to 12 puffs/day) [C] Symptoms controlled? ***Note: Assure adherence to medication treatment before escalating therapy
Daily symptoms OR FEV1 less than 50% predicted [B] Inhaled anticholinergic (2-6 puffsquid) or combination therapy with inhaled anticholinergics and short acting beta2-agonist (2-4 puffs pm up to 12 puffs/day) [D] Symptoms controlled? ***Note: Assure adherence to medication treatment before escalating therapy
Consider adding long-acting inhaled beta2-agonist [F] Symptoms controlled? ***Note: Assure adherence to medication treatment before escalating therapy
Consider theophylline trial (slow-release adjusted to 5-12 microg/ml) [G] Symptoms controlled? ***Note: Assure adherence to medication treatment before escalating therapy
Consider corticosteroid trial (prednisone 40-60 mg qd or high-dose inhaled corticosteroids (14-21 days)) [H] Box 13 no to box 14
Symptoms controlled? Taper to lowest effective dose. Consider consultation with specialist [H]
Refer to specialist promptly Review precautions and recommendations for medication [I]
*** Assure adherence to medication treatment before escalating therapy