A 62-year-old man with COPD (FEV₁ 45% predicted) experiences persistent dyspnea despite regular use of short-acting beta-2 agonist (SALBUTAMOL). He has no history of asthma. What is the drug of choice for maintenance therapy?

Explanation

## Maintenance Therapy in COPD **Key Point:** Long-acting bronchodilators — either **LAMA (e.g., tiotropium)** or **LABA (e.g., salmeterol)** — are the cornerstone of maintenance therapy in COPD. Either class is appropriate as monotherapy for moderate COPD. ### Rationale for Long-Acting Bronchodilators **High-Yield:** COPD pathophysiology is primarily **airflow obstruction** (loss of elastic recoil, small airway collapse), not inflammation. Long-acting bronchodilators provide sustained symptom relief and improve exercise capacity. | Feature | LAMA | LABA | ICS | Theophylline | Ipratropium TID | |---------|------|------|-----|--------------|------------------| | **Mechanism** | Anticholinergic | β₂-agonist | Anti-inflammatory | Phosphodiesterase inhibitor | Anticholinergic | | **Duration** | 24 hours | 12 hours | — | 8–12 hours | 6–8 hours | | **First-line for COPD** | Yes | Yes | No (only if asthma overlap) | No | No (SABA preferred) | | **Improves FEV₁** | Yes | Yes | Minimal | Modest | Yes | | **Reduces exacerbations** | Yes | Yes | Only if asthma overlap | No | No | | **Cardiovascular risk** | None | Minimal | — | Arrhythmias (narrow TI) | None | ### Why NOT ICS in Pure COPD? **Clinical Pearl:** ICS is NOT recommended as monotherapy in COPD unless there is asthma overlap (asthma-COPD overlap syndrome, ACOS). Pure COPD patients do not have significant eosinophilic airway inflammation and do not benefit from ICS alone. ICS is added only if exacerbations are frequent (≥2/year) and the patient is already on LABA. **Warning:** Do not confuse asthma with COPD — the pharmacological approach differs fundamentally. Asthma = inflammation → ICS first. COPD = obstruction → long-acting bronchodilators first. **Mnemonic:** **COPD Maintenance Ladder** — Mild: SABA PRN → Moderate: LAMA or LABA → Severe: LAMA + LABA → Very severe + exacerbations: LAMA + LABA + ICS. [cite:GOLD 2023 Global Strategy for the Diagnosis, Management and Prevention of COPD]