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2015 ; 116
(4
): 291-307
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Diagnosis and pharmacotherapy of stable chronic obstructive pulmonary disease:
the finnish guidelines
#MMPMID25515181
Kankaanranta H
; Harju T
; Kilpeläinen M
; Mazur W
; Lehto JT
; Katajisto M
; Peisa T
; Meinander T
; Lehtimäki L
Basic Clin Pharmacol Toxicol
2015[Apr]; 116
(4
): 291-307
PMID25515181
show ga
The Finnish Medical Society Duodecim initiated and managed the update of the
Finnish national guideline for chronic obstructive pulmonary disease (COPD). The
Finnish COPD guideline was revised to acknowledge the progress in diagnosis and
management of COPD. This Finnish COPD guideline in English language is a part of
the original guideline and focuses on the diagnosis, assessment and
pharmacotherapy of stable COPD. It is intended to be used mainly in primary
health care but not forgetting respiratory specialists and other healthcare
workers. The new recommendations and statements are based on the best evidence
available from the medical literature, other published national guidelines and
the GOLD (Global Initiative for Chronic Obstructive Lung Disease) report. This
guideline introduces the diagnostic approach, differential diagnostics towards
asthma, assessment and treatment strategy to control symptoms and to prevent
exacerbations. The pharmacotherapy is based on the symptoms and a clinical
phenotype of the individual patient. The guideline defines three clinically
relevant phenotypes including the low and high exacerbation risk phenotypes and
the neglected asthma-COPD overlap syndrome (ACOS). These clinical phenotypes can
help clinicians to identify patients that respond to specific pharmacological
interventions. For the low exacerbation risk phenotype, pharmacotherapy with
short-acting ?2 -agonists (salbutamol, terbutaline) or anticholinergics
(ipratropium) or their combination (fenoterol-ipratropium) is recommended in
patients with less symptoms. If short-acting bronchodilators are not enough to
control symptoms, a long-acting ?2 -agonist (formoterol, indacaterol, olodaterol
or salmeterol) or a long-acting anticholinergic (muscarinic receptor antagonists;
aclidinium, glycopyrronium, tiotropium, umeclidinium) or their combination is
recommended. For the high exacerbation risk phenotype, pharmacotherapy with a
long-acting anticholinergic or a fixed combination of an inhaled glucocorticoid
and a long-acting ?2 -agonist (budesonide-formoterol, beclomethasone
dipropionate-formoterol, fluticasone propionate-salmeterol or fluticasone
furoate-vilanterol) is recommended as a first choice. Other treatment options for
this phenotype include combination of long-acting bronchodilators given from
separate inhalers or as a fixed combination (glycopyrronium-indacaterol or
umeclidinium-vilanterol) or a triple combination of an inhaled glucocorticoid, a
long-acting ?2 -agonist and a long-acting anticholinergic. If the patient has
severe-to-very severe COPD (FEV1 < 50% predicted), chronic bronchitis and
frequent exacerbations despite long-acting bronchodilators, the pharmacotherapy
may include also roflumilast. ACOS is a phenotype of COPD in which there are
features that comply with both asthma and COPD. Patients belonging to this
phenotype have usually been excluded from studies evaluating the effects of drugs
both in asthma and in COPD. Thus, evidence-based recommendation of treatment
cannot be given. The treatment should cover both diseases. Generally, the therapy
should include at least inhaled glucocorticoids (beclomethasone dipropionate,
budesonide, ciclesonide, fluticasone furoate, fluticasone propionate or
mometasone) combined with a long-acting bronchodilator (?2 -agonist or
anticholinergic or both).
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