Respiratory  |  COPD Pathway - Regular Medications


COPD Pathway - Regular Medications

In general, non pharmacological interventions (smoking cessation, pulmonary rehabilitation) are just as important as drug treatments for COPD.

Medications help some, but not all, patients with COPD. Trial regular treatment for at least one month, or longer for inhaled steroids, and assess response . No content in this box Discontinue if not beneficial. Ensure that patient education and inhaler technique is adequate.

Using your inhaler - how to videos

Assess treatment response:

  • Has your treatment made a difference to you?
  • Is your breathing easier in any way?
  • Has your sleep improved?
  • Can you do some things now that you couldn't do at all before, or do the same things faster? Give examples.
  • Can you do the same things as before but are now less breathless when you do them? Give examples.


Trial in the following order

Short acting bronchodilators:

  • Beta 2-agonist (salbutamol) / Bricanyl(terbutaline) or
  • Anticholinergic (ipratropium).

These may improve symptoms and exercise tolerance, and reduce the number of exacerbations.

Duolin HFA:

Duolin HFA , the combined salbutamol / ipratropium inhaler, replaces Combivent  from February 2011. The majority of patients can be continued on beta agonist alone for their reliever. If side effects of high use of beta agonists are an issue (tremor, palpitations, hypertension), consider addition of ipratropium inhaler. However, such a patient, if severe enough, might also benefit from long-acting bronchodilators.  Recent evidence suggests there may be dangers of LABA use alone in asthma but not in COPD . Conjunct use of steroid inhaler is recommended with LABA in Asthma.

Long acting bronchodilators:

  • Long acting Beta 2-agonist (LABA) - eformoterol (Oxis®) or salmeterol (Serevent®)

    • provides bronchodilation for 12h
    • Long acting anticholinergic - tiotropium (Spiriva®)

      • provides bronchodilation for over 24h, is given once daily, and needs special authority; FEV1 and MRC dyspnoea scale  criteria apply .
      • Note MRC (Medical Research Council) Breathlessness Scale
      • Do not co-prescribe tiotropium and ipratropium due to decreased effectiveness of tiotropium and risk of tachycardia. Use salbutamol as the reliever
      • These may improve symptoms and exercise tolerance, and reduce the number of exacerbations.

Inhaled Steroids:

  • Inhaled Steroids - if frequent (>2 per year) exacerbations, and moderate/severe COPD.
  • Trial may need to be for up to 6 months.

Note: There is possibly an increased risk of pneumonia while on high dose inhaled steroids.

Practice Point!

Only 25% of COPD patients will obtain significant benefit from inhaled corticosteroids.

Theophylline preparations:

Theophylline preparations may be of benefit for some selected patients, but are not commonly used.

  • Start low dose e.g., Theodur SR 250 mg od. At such low doses, monitoring of blood levels is not generally required.
  • Main adverse effects are nausea and tachycardia, and there are multiple potential drug interactions.


  • Mucolytics (such as Bromhexine 8 mg tds) may be useful for some patients struggling to expectorate.
  • May also reduce the frequency and duration of exacerbations in patients not treated with inhaled steroids.
  • Are not currently funded in New Zealand.


Oxygen Therapy:

  • If there is evidence of chronic hypoxaemia in those with severe disease (02 saturation at rest < 90% on more than one occasion). This is contra-indicated in patients who are current smokers.

Palliative Medications:

Palliative medications for end stage disease, ie, morphine elixir.

Note: Prednisone may be useful for acute exacerbations but should not be used long term due to the risk of adverse effects.

Last updated : Wednesday, March 30, 2016
Next review date : Thursday, March 30,2017

Disclaimer: This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.