Effective treatment often requires you to take medications to better manage symptoms or stop taking medications if a doctor advises that you no longer need them.
Finding the right dosages and combination of medications to treat chronic obstructive pulmonary disease (COPD) often requires an approach known as stepwise treatment. This method involves adding or removing certain medications to or from your treatment plan, as well as increasing or decreasing their dosages.
Stepwise treatment can be time consuming, but it’s a well-established means of better managing your symptoms. The stepwise approach also requires working closely with your healthcare team and being proactive about reporting medication side effects or changes in your symptoms.
COPD is the name given to a group of conditions, including chronic bronchitis and emphysema. These conditions make breathing difficult and can diminish your quality of life. While there is no current cure for COPD, you can often manage it with proper treatment.
Treatment usually involves:
- oxygen therapy
- lifestyle modifications that support better lung and airway function
The term “stepwise treatment” refers to “stepping up” (increasing) or “stepping down” (decreasing) your medications to achieve effective symptom management.
Stepping up means escalating your treatment by adding additional medications or increasing the strength or dosage of your current medications. This is done if a doctor determines that your condition isn’t adequately managed yet.
Stepping down means de-escalating your treatment. It usually involves reducing the number of medications you’re taking or lowering one or more dosages. The goal is always for you to take as few medications at the lowest dosages necessary for safe but effective treatment.
Most COPD stepwise treatment guidelines address when certain kinds of medications should be added to your treatment plan if symptoms are not well managed.
The 2023 guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) make several key points about how the presence of certain symptoms should drive the decision to add new medications.
For example, the GOLD guidelines recommend a step up to a combination of a long-acting beta-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) for people with persistent dyspnea (shortness of breath) and significant exercise limitations — even with the use of a bronchodilator. A bronchodilator is a type of inhaled medication that relaxes the lungs and widens the airways to make breathing easier.
If this doesn’t improve symptoms, you may need to try different inhaler devices for your bronchodilator, or your care team may need to investigate other possible causes of dyspnea.
The GOLD guidelines also suggest that people who use bronchodilators and have exacerbations — sudden symptom flare-ups or episodes of worsening of symptoms — should also be stepped up with LABA and LAMA therapy, even if they do not have dyspnea. LABA and LAMA therapy may be referred to as LABA+LAMA.
If your levels of eosinophils (a type of pro-inflammatory white blood cell) at or above 300
If you have persistent exacerbations while undergoing LABA+LAMA treatment, a doctor may recommend an ICS if your blood eosinophil levels are less than 100 cells·µL−1.
Stepwise guidelines are just recommendations, though. The question of increasing treatment still requires a thorough evaluation by a doctor of how your COPD responds to medication and whether you are taking the drug precisely as directed.
The GOLD guidelines offer fewer recommendations for stepping down treatment. Reducing your COPD treatment requires you to pay close attention to your symptoms.
If reducing a medication’s dosage or removing it from your treatment plan entirely causes a return of symptoms, you must tell your healthcare team as soon as possible.
- chest tightness or heaviness
- ongoing cough
- shortness of breath
- wheezing or whistling as you breathe
You may not have all of these symptoms if you have COPD. Over time, some symptoms may change depending on treatment and the progression of the condition.
Using GOLD criteria, individuals with COPD are assigned a grade (1 through 4). This is based on the results of spirometry tests, which measure how much air you can inhale and exhale and how quickly you can expel all the air from your lungs.
The amount you can exhale in 1 second is called forced expiratory volume (FEV1). The percentage of your expected FEV1 score helps determine your GOLD grade. The expected amount of exhaled air is based on averages of people without COPD who share the same age, sex, and height.
COPD grades include:
- Grade 1: mild COPD, 80% of expected FEV1 value
- Grade 2: moderate COPD, 50–79% of expected FEV1 value
- Grade 3: severe COPD, 30–49% of expected FEV1 value
- Grade 4: very severe COPD, less than 30% of expected FEV1 value
Your COPD will also be categorized into groups A, B, or E based on your symptoms and history of exacerbations. The GOLD criteria for grouping includes the use of the Modified Medical Research Council (mMRC) Dyspnoea Scale, a gauge of dyspnea on a scale of 0 through 4:
- 0: means you are breathless only with strenuous physical activity
- 1: means you become breathless walking briskly or up a slight incline
- 2: means your shortness of breath causes you to walk slower than your peers or requires you to take breaks
- 3: means you need a break after walking 100 yards or after just a few minutes
- 4: means your dyspnea makes it difficult to leave the house or engage in simple activities such as dressing
Using the mMRC scale as part of the criteria, here are the explanations for groups A, B, and E:
- Group A: means you have had one exacerbation or no exacerbations per year (not requiring hospitalization) and an mMRC score of 0 or 1
- Group B: also includes people who have had one or no exacerbations (not requiring hospitalization) per year and an mMRC score of 2 or higher
- Group E: means you have had at least two exacerbations per year (not requiring hospitalization) or at least one exacerbation per year requiring you to be hospitalized and includes any mMRC score
The American Lung Association recommends developing a COPD action plan with your healthcare team. The plan includes information and strategies to help you respond to changes in your symptoms, as well as when it’s time to consult with your healthcare team about possible treatment changes.
If, for example, your symptoms don’t improve after home treatment (such as a quick-relief inhaler), you should contact your doctor.
If you have some or all of the following symptoms, you should call 911 or your local emergency number:
- blue coloring in your lips or fingertips
- severe shortness of breath
- sudden and severe chest pain or pressure
Stepwise treatment for COPD can be a lengthy process as you and your healthcare team come up with a medication regimen that works well for you. It’s important to be upfront with your team about changes in your symptoms.
COPD is a chronic respiratory condition, which means you will likely need to make changes to your treatment plan at different times.
Be prepared to make significant lifestyle changes, such as quitting smoking and adjusting your physical activity levels, to help stay healthy while also allowing for limitations to your ability to exercise.