Canadian Thoracic Society Clinical Practice Guideline on pharmacotherapy in patients with COPD ? 2019 update of evidence
Canadian Thoracic Society Clinical Practice Guideline on pharmacotherapy in patients with COPD ? 2019 update of evidence
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DOI：
10.1080/24745332.2019.1668652
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发表时间：
2019-10-18
影响因子：
0.8
通讯作者：
Marciniuk, Darcy D.
中科院分区：
文献类型：
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作者：
Bourbeau, Jean;Bhutani, Mohit;Marciniuk, Darcy D.
在本指南更新中，我们强调了与慢性阻塞性肺疾病（COPD）药物治疗相关的重要和新发现，这些发现应该改变临床实践并改善疾病管理。我们提出了稳定期COPD患者维持药物治疗的最新证据、建议和专家临床评论。COPD的诊断和非药物治疗不在本次更新的范围内。对于尽管使用吸入性LAMA或LABA单药治疗但仍持续呼吸短促、运动不耐受和/或健康状况不佳的COPD患者，我们建议在LAMA/LABA双联治疗基础上增加治疗。在高风险急性加重患者中，LAMA/LABA是ICS/LABA的首选，但既往急性加重患者外周嗜酸性粒细胞增多症较高的情况除外。ICS单药治疗没有作用;如有指征，ICS仅应与支气管扩张剂联合使用。治疗？站出来在COPD中，吸入联合治疗优于单药治疗，三联治疗优于双联治疗。因为吸入性三联或双联支气管扩张剂治疗的优越性可能不是在每个患者身上都能实现，？下台？对于某些患者（未来急性加重的风险不高），可以考虑使用，但应在密切的医疗监督下进行，因为临床恶化的风险是真实的，并继续存在。应在对患者和治疗改变的潜在获益进行全面评价，以及对治疗的任何不良反应进行评估，并审查患者依从性、吸入器技术和患者偏好后，做出改变治疗的决定。药物治疗在治疗中起着基础性作用，但它不应该是管理COPD患者的唯一治疗方法。临床医生应始终结合联合收割机并优化药物和非药物治疗，以达到减轻症状和预防COPD急性加重（AECOPD）的双重目标。
In this guideline update, we highlight important and new findings related to pharmacological therapy of chronic obstructive pulmonary disease (COPD) that should change clinical practice and improve disease management. We present updated evidence, recommendations and expert clinical remarks on maintenance pharmacotherapy in patients with stable COPD. The diagnosis and nonpharmacological therapy of COPD are out-of-scope for this update. In patients with COPD who have persistent shortness of breath, exercise intolerance and/or poor health status despite using inhaled LAMA or LABA monotherapy, we recommend augmenting treatment to LAMA/LABA dual therapy. In patients with high-risk exacerbations, LAMA/LABA is the preferred choice to ICS/LABA except in patients with previous exacerbations who have higher peripheral eosinophilia. There is no role for ICS monotherapy; when indicated, ICS should only be used in combination with bronchodilators. Treatment ?step up? in COPD is proposed as a practical construct supported by evidence that inhaled combined therapy is superior to monotherapy and triple therapy to dual therapy in certain patient populations. Because the superiority of inhaled triple or dual bronchodilator therapy may not be achieved in every patient, ?step down? may be considered for some patients (not at high risk for future exacerbations), but should be done with close medical supervision, as the risk of clinical deterioration is real and continues to exist. The decision of changing a therapy should always occur after a complete evaluation of the patient and the potential benefit to a change in therapy; as well as an assessment of any adverse effects of the therapy, and with a review of patient adherence, inhaler technique and patient preferences. Pharmacological therapy plays a foundational role in therapy, but it should never be the sole treatment in managing COPD patients. Clinicians should always combine and optimize pharmacological and nonpharmacological therapies with the dual goals of reducing symptoms and preventing acute exacerbations of COPD (AECOPD).