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What to know about COPD stepwise therapyMedically reviewed by Adithya Cattamanchi, M.D., Pulmonology — By Zia Sherrell, MPH on July 29, 2022COPD stepwise therapy is an individualized treatment approach for chronic obstructive pulmonary disease (COPD). As COPD is a progressive condition, treatment typically becomes more intensive over time. However, with stepwise therapy, a person can move up or down the treatment spectrum depending on the status of their condition.
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This approach helps avoid both overtreatment and undertreatment. Traditional COPD treatment depends on the severity of an individual’s symptoms and how well they can breathe.
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It often begins with bronchodilators that help open the airways. A doctor may then add bronchodilators from a different class, inhaled corticosteroids, and pulmonary rehabilitation.
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COPD stepwise therapy involves the same treatment options, but doctors will add them or take them away according to the person’s health at the time of their checkup. This article looks at COPD stepwise therapy in more detail, including its benefits and alternatives.
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It also discusses alternative treatment approaches. What is COPD stepwise therapy
Share on PinterestBlake Little/Getty ImagesCOPD stepwise therapy is a type of treatment approach for COPD, which is an umbrella term for conditions that cause difficulty breathing.
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It aims to simplify treatment according to disease severity. As COPD is a progressive condition, doctors have traditionally believed that treatment should become more intensive over time.
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However, more recently, some experts have challenged this school of thought. They think that in specific scenarios, it could make sense to de-escalate, or step down, the treatment.
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Stepwise therapy is an individualized approach to COPD treatment that requires ongoing assessment and monitoring of an individual’s health. Doctors must first critically evaluate the person and diagnose their condition.
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The person may have:COPD and asthma overlapCOPD with frequent exacerbations, which is when the symptoms worsen for a periodCOPD without frequent exacerbations
The doctor follows guidelines for step-ups in treatment as the COPD progresses. For example, someone with COPD without frequent exacerbations may begin by taking a long-acting beta-agonist (LABA) or a long-acting muscarinic antagonist (LAMA). These medications help improve lung function and shortness of breath and reduce the risk of exacerbations.
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If a person’s symptoms worsen, the next step up may be pulmonary rehabilitation. A doctor may recommend a specialized evaluation if rehabilitation does not help. In the case that a person’s symptoms improve, a doctor may consider stepping down their treatment.
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This involves removing a specific medication from the person’s treatment regimen. GOLD guidelines for COPD
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines are a widely used, evidence-based approach to COPD treatment.
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They provide recommendations for managing the condition. GOLD guidelines recommend an individual’s initial treatment depending on their GOLD group at the time of diagnosis.
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Doctors should prescribe short-acting bronchodilators to all individuals with COPD. These medications provide immediate symptom relief. In addition to these, a doctor will prescribe medication depending on a person’s GOLD classification:Group A: These individuals have few symptoms and are at low risk of exacerbations.
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Doctors will prescribe a short- or long-acting bronchodilator as the first line of treatment.Group B: These individuals have more symptoms but still have a low risk of exacerbations. Doctors should prescribe a long-acting bronchodilator — either a LAMA or a LABA. For people with severe breathlessness, doctors may recommend two bronchodilators of different classes.Group C: These individuals have few symptoms but a higher risk of exacerbations.
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Their first-line treatment should be a LAMA, as these medications reduce the risk of exacerbations more effectively than LABAs in people with moderate to severe COPD.Group D: These individuals have more symptoms and a high risk of exacerbations. Therefore, doctors may recommend beginning treatment with a LAMA, a LABA and LAMA combination, or a combination of an inhaled corticosteroid with a LABA.
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For most people, a LAMA is the first choice. Pros and cons of stepwise therapy
The primary benefit of stepwise therapy is that it avoids overtreatment. It aims to optimize a person’s treatment protocol and reduce excessive medications.
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However, doctors may find it challenging to determine when they are overtreating someone. There are no known biomarkers that indicate how the body is responding to treatment.
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Therefore, doctors must make their treatment decisions on the basis of a person’s symptoms, which can make it difficult to know when to step down treatment. Overall, there is a lack of evidence for this approach, and de-escalating treatment is controversial.
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Other treatment strategies
The alternative to stepwise therapy is a hit-hard approach. This means prescribing more medications and aiming for maximum bronchodilation. For people in group A, this strategy involves using two bronchodilators instead of one.
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Doctors may recommend this approach because:This group has a similar mortality rate to group C, so the condition warrants a more aggressive treatment approach.Some people using a single long-acting bronchodilator still have significant symptoms.Using two bronchodilators may provide better symptom relief. It may also help people do more physical activity, which can improve overall health.
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Summary
The stepwise approach is an individualized approach to treating COPD. It involves starting with the minimum amount of treatment and increasing it as necessary. If a person’s symptoms improve, a doctor may recommend reducing, or stepping down, the treatment.
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The primary benefit of the stepwise approach is that it avoids overtreatment. However, there is a lack of evidence for this method, and de-escalating treatment remains controversial.
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An alternative to stepwise therapy is a hit-hard approach that involves using more medications to relieve the symptoms. Last medically reviewed on July 29, 2022COPDPulmonary SystemRespiratory 5 sourcescollapsedMedical News Today has strict sourcing guidelines and draws only from peer-reviewed studies, academic research institutions, and medical journals and associations.
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We avoid using tertiary references. We link primary sources — including studies, scientific references, and statistics — within each article and also list them in the resources section at the bottom of our articles.
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You can learn more about how we ensure our content is accurate and current by reading our editorial policy.2022 GOLD reports. (2022).https://goldcopd.org/2022-gold-reports-2/Chronic obstructive pulmonary disease (COPD). (n.d.).https://bestpractice.bmj.com/topics/en-us/7/management-approachFerreira, A.
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J., et al. (2016).
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COPD: A stepwise or a hit hard approach?https://www.journalpulmonology.org/en-copd-a-stepwise-or-hit-articulo-S2173511516000129Koarai, A., et al. (2020). Treatment with LABA versus LAMA for stable COPD: A systematic review and meta-analysis. https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-020-1152-8López-Campos, J.
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L., et al. (2021). Step-up and step-down treatment approaches for COPD: A holistic view of progressive therapies.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8285922/FEEDBACK:Medically reviewed by Adithya Cattamanchi, M.D., Pulmonology — By Zia Sherrell, MPH on July 29, 2022
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