J Bras Pneumol. 2017;43(4):290-301
http://dx.doi.org/10.1590/S1806-37562017000000153 SPECIAL ARTICLE
Recommendations for the pharmacological
treatment of COPD: questions and answers
Frederico Leon Arrabal Fernandes1, Alberto Cukier1, Aquiles Assunção Camelier2,3,
Carlos Cezar Fritscher4, Cláudia Henrique da Costa5,
Eanes Delgado Barros Pereira6, Irma Godoy7, José Eduardo Delfini Cançado8,
1. Divisão de Pneumologia, Instituto do José Gustavo Romaldini8, Jose Miguel Chatkin4, José Roberto Jardim9,
Coração – InCor − Hospital das Clínicas,
Faculdade de Medicina, Universidade Marcelo Fouad Rabahi10, Maria Cecília Nieves Maiorano de Nucci11,
de São Paulo, São Paulo (SP) Brasil. Maria da Penha Uchoa Sales12, Maria Vera Cruz de Oliveira Castellano13,
2. Universidade do Estado da Bahia – Miguel Abidon Aidé14, Paulo José Zimermann Teixeira15,16, Renato Maciel17,
UNEB – Salvador (BA) Brasil.
3. Escola Bahiana de Medicina e Saúde Ricardo de Amorim Corrêa18, Roberto Stirbulov8, Rodrigo Abensur Athanazio1,
Pública, Salvador (BA) Brasil. Rodrigo Russo19, Suzana Tanni Minamoto7, Fernando Luiz Cavalcanti Lundgren20
4. Faculdade de Medicina, Pontifícia
Universidade Católica do Rio Grande do
Sul − PUCRS− Porto Alegre (RS)Brasil. ABSTRACT
5. Universidade Estadual do Rio de
Janeiro, Rio de Janeiro (RJ) Brasil. The treatment of COPD has become increasingly effective. Measures that range from
6. Universidade Federal do Ceará, behavioral changes, reduction in exposure to risk factors, education about the disease
Fortaleza (CE) Brasil. and its course, rehabilitation, oxygen therapy, management of comorbidities, and surgical
7. Departamento de Medicina Interna, and pharmacological treatments to end-of-life care allow health professionals to provide
Área de Pneumologia, Faculdade de a personalized and effective therapy. The pharmacological treatment of COPD is one of
Medicina de Botucatu, Universidade the cornerstones of COPD management, and there have been many advances in this
Estadual Paulista – UNESP –
Botucatu (SP) Brasil. area in recent years. Given the greater availability of drugs and therapeutic combinations,
8. Faculdade de Ciências Médicas, Santa it has become increasingly challenging to know the indications for, limitations of, and
Casa de Misericórdia de São Paulo, potential risks and benefits of each treatment modality. In order to critically evaluate
São Paulo (SP) Brasil. recent evidence and systematize the major questions regarding the pharmacological
9. Faculdade de Medicina, Escola Paulista treatment of COPD, 24 specialists from all over Brazil gathered to develop the present
de Medicina, Universidade Federal de
São Paulo, São Paulo (SP) Brasil.
recommendations. A visual guide was developed for the classification and treatment
10. Faculdade de Medicina, Universidade of COPD, both of which were adapted to fit the situation in Brazil. Ten questions were
Federal de Goiás, Goiânia (GO) Brasil. selected on the basis of their relevance in clinical practice. They address the classification,
11. AC Camargo Cancer Center, definitions, treatment, and evidence available for each drug or drug combination. Each
São Paulo (SP) Brasil. question was answered by two specialists, and then the answers were consolidated
12. Hospital de Messejana Dr Carlos Alberto in two phases: review and consensus by all participants. The questions answered are
Studart Gomes, Fortaleza (CE) Brasil. practical questions and help select from among the many options the best treatment for
13. Serviço de Pneumologia, Hospital do each patient and his/her peculiarities.
Servidor Público Estadual de São Paulo,
São Paulo (SP) Brasil. Keywords: Pulmonary disease, chronic obstructive/drug therapy; pulmonary disease,
14. Faculdade de Medicina, Universidade chronic obstructive/prevention & control; pulmonary disease, chronic obstructive/therapy.
Federal Fluminense, Niterói (RJ) Brasil.
15. Departamento de Clínica Médica,
Universidade Federal de Ciências da INTRODUCTION
Saúde de Porto Alegre,
Porto Alegre (RS) Brasil.
The treatment of COPD has become increasingly effective. Measures that range from
16. Universidade FEEVALE, Campus II, behavioral changes, reduction in exposure to risk factors, education about the disease
Novo Hamburgo (RS) Brasil. and its course, rehabilitation, oxygen therapy, management of comorbidities, and
17. Disciplina de Pneumologia, Faculdade surgical and pharmacological treatments to end-of-life care allow health professionals
de Ciências Médicas de Minas Gerais, to provide a personalized and effective therapy. However, having accurate knowledge
Belo Horizonte (MG) Brasil.
18. Faculdade de Medicina, Hospital das of the indications for, limitations of, and potential risks and benefits of each treatment
Clínicas, Universidade Federal de Minas modality has become a challenge. This challenge is even more acute when we have
Gerais, Belo Horizonte (MG) Brasil. to adapt evidence in the literature to fit the peculiarities of our country, given the
19. Departamento de Medicina, frequent challenges faced in both public and private clinical practice.
Universidade Federal de São João Del Rei
– UFSJ − São João Del Rei (MG) Brasil. The pharmacological treatment of COPD is one of the cornerstones of COPD
20. Hospital Otavio de Freitas, management, and there have been many advances in this area in recent years.(1)
Recife (PE), Brasil.
In 2011, a systematic review of the advances in the pharmacological treatment of
Submitted: 8 May 2017. COPD was published in the JBP. It is striking the extent to which the knowledge of
Accepted: 4 July 2017. and the resources available to treat COPD have evolved since then.(2)
Study carried out in the Divisão de The individualization of treatment is essential and should be based on the availability
Pneumologia, Instituto do Coração – InCor
of existing drugs, disease severity, patient preferences, drug interactions, and
− Hospital das Clínicas, Faculdade de
Medicina, Universidade de São Paulo, comorbidities. The goal should always be to meet the disease control objectives
São Paulo (SP) Brasil. effectively. In order to critically evaluate recent evidence and systematize the major
Correspondence to:
Frederico Leon Arrabal Fernandes. Avenida Dr. Enéas de Carvalho Aguiar, 44, Secretaria da Pneumologia, CEP 05403-900, São Paulo, SP, Brasil.
Tel./Fax: 55 11 2661-5034. E-mail: fredlaf@gmail.com
Financial support: None.
290 © 2017 Sociedade Brasileira de Pneumologia e Tisiologia ISSN 1806-3713
, Fernandes FLA, Cukier A, Camelier AA, Fritscher CC, Costa CH, Pereira EDB, Godoy I, Cançado JED, Romaldini JG, Chatkin JM,
Jardim JR, Rabahi MF, Nucci MCNM, Sales MPU, Castellano MVCO, Aidé MA, Teixeira PJZ, Maciel R, Corrêa RA, Stirbulov R,
Athanazio RA, Russo R, Minamoto ST, Lundgren FLC
questions regarding the pharmacological treatment Chart 1 shows the major drugs available for the
of COPD, specialists from all over Brazil gathered to treatment of COPD, and Chart 2 serves as a guide
develop the present recommendations. for the classification and treatment of COPD, both of
It is always important to emphasize that the which were adapted to fit the situation in Brazil. The 10
pharmacological treatment of COPD should be questions answered in the present recommendations
complemented by measures such as smoking cessation, are practical questions and help select from among the
encouragement for physical activity, pulmonary many options the best treatment for each COPD patient.
rehabilitation, and vaccination to prevent viral infections
and pneumonia, as well as by measures against advanced 1. HOW SHOULD COPD SEVERITY BE
disease, such as oxygen therapy, surgical treatment, CLASSIFIED?
endoscopic treatment, and lung transplantation.(3) These
treatment measures should always be considered and, The first international consensus guidelines on COPD
when indicated, should be implemented together with used the degree of FEV1 impairment for determining
the appropriate drug therapy.(4) disease severity. Current guidelines, however, combine
Chart 1. Main drugs for the treatment of COPD.a
Drug Dose, µg (except where otherwise indicated) Duration of action, h
Short-acting β2 agonist
Fenoterol MDI 100 and 200 4a6
Albuterol MDI 100, 120, 200 4 to 6, 12
Long-acting β2 agonist
Formoterol DPI 12 12
Salmeterol MDI 25 and DPI 50 12
Indacaterol DPI 150 and 300 24
Olodaterol SMI 2.5 24
Short-acting anticholinergic
Ipratropium (bromide) MDI 20 e 40 6 to 8
Long-acting anticholinergic
Glycopyrronium (bromide) DPI 50 12 to 24
Tiotropium SMI 2.5 24
Umeclidinium (bromide) DPI 62.5 24
β2 agonist plus short-acting anticholinergic
Fenoterol/ipratropium MDI 50/20 6 to 8
Albuterol/ipratropium MDI 120/20 6 to 8
β2 agonist plus long-acting anticholinergic
Formoterol/aclidinium DPI 12/400 12
Formoterol/glycopyrronium MDI 9.6/14.4 12
Indacaterol/glycopyrronium DPI 110/50 12 to 24
Vilanterol/umeclidinium DPI 25/62.5 24
Olodaterol/tiotropium SMI 2.5/2.5 24
Long-acting β2 agonist plus inhaled corticosteroid
Formoterol/beclomethasone MDI and DPI 6/100 12
Formoterol/budesonide DPI 6/200, 12/400, and 12/200 12
MDI 6/200
Formoterol/mometasone MDI 5/50, 5/100, and 5/200 12
Salmeterol/fluticasone DPI 5/100, 50/250, and 50/500 12
MDI 25/50, 25/125, and 25/250
Vilanterol/fluticasone DPI 25/100 24
Phosphodiesterase-4 inhibitor
Roflumilast Tablet, 500 mg 24
Macrolide
Azithromycin Tablet or capsule, 250 and 500 mg 24
Mucolytic
N-acetylcysteine Powder, 200 and 600 mg; syrup, 30 mg/mL; 8 to 12
and tablet, 600 mg
MDI: metered dose inhaler; DPI: dry powder inhaler; and SMI: soft mist inhaler. aIn bold, formulations currently
available in Brazil. The others are, at the time of this publication, in the process of approval by the Brazilian National
Health Oversight Agency or in the process of being released by the pharmaceutical industry.
J Bras Pneumol. 2017;43(4):290-301 291
