Pharmacotherapy in Patients With Stable COPD

Authoring Organization

Publication Month/Year

September 8, 2023

Last Updated Month/Year

November 6, 2023

Document Type


Country of Publication


Document Objectives

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.

Target Patient Population

All individuals with stable COPD

Target Provider Population

Pulmonologists, family medicine, and other allied clinicians caring for patients with stable COPD

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings


Intended Users

Nurse, nurse practitioner, physician, physician assistant


Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D029424 - Pulmonary Disease, Chronic Obstructive


chronic obstructive pulmonary disease (COPD), COPD, COPD exacerbation, LAMA, Chronic Obstructive Pulmonary Disease, stable COPD, LABA

Source Citation

Jean Bourbeau, Mohit Bhutani, Paul Hernandez, Shawn D. Aaron, Marie-France Beauchesne, Sophie B. Kermelly, Anthony D’Urzo, Avtar Lal, François Maltais, Jeffrey D. Marciniuk, Sunita Mulpuru, Erika Penz, Don D. Sin, Anne Van Dam, Joshua Wald, Brandie L. Walker, Darcy D. Marciniuk, 2023 Canadian Thoracic Society Guideline on Pharmacotherapy in Patients With Stable COPD,
CHEST, 2023, ISSN 0012-3692, https://doi.org/10.1016/j.chest.2023.08.014


Number of Source Documents
Literature Search Start Date
October 18, 2018
Literature Search End Date
June 9, 2022