Table 2.

Recommendations for the Pharmacologic Treatment of Stable Chronic Obstructive Pulmonary Disease

PICO Question	Recommendation	Strength of Recommendation	Certainty of Evidence
1. In patients with COPD who complain of dyspnea or exercise intolerance, is LABA/LAMA combination therapy more effective than and as safe as LABA or LAMA monotherapy?	In patients with COPD who complain of dyspnea or exercise intolerance, we recommend LABA/LAMA combination therapy over LABA or LAMA monotherapy.	Strong	Moderate certainty
2. In patients with COPD who complain of dyspnea or exercise intolerance despite the use of dual therapy with LABA/LAMA, is triple therapy with ICS/LABA/LAMA more effective than and as safe as dual therapy with LABA/LAMA?	In patients with COPD who complain of dyspnea or exercise intolerance despite dual therapy with LABA/LAMA, we suggest the use of triple therapywith ICS/LABA/LAMA over dual therapy with LABA/LAMA in those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization.	Conditional	Moderate certainty
3. In patients with COPD who are receiving triple therapy (ICS/LABA/LAMA), should the ICS be withdrawn?	In patients with COPD who are receiving triple therapy (ICS/LABA/LAMA), we suggest that the ICS can be withdrawn if the patient has had no exacerbations in the past year.	Conditional	Moderate certainty
4. In patients with COPD and blood eosinophilia, should treatment include an ICS in addition to a long-acting bronchodilator?	We do not make a recommendation for or against ICS as an additive therapy to long-acting bronchodilators in patients with COPD and blood eosinophilia, except for those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization, for whom we suggest ICS as an additive therapy.	Conditional	Moderate certainty
5. In patients with COPD who have a history of severe and frequent exacerbations despite otherwise optimal therapy, is maintenance oral steroid therapy more effective than and as safe as no maintenance oral steroid therapy?	In patients with COPD and a history of severe and frequent exacerbations despite otherwise optimal therapy, we advise against the use of maintenance oral corticosteroid therapy.	Conditional	Low certainty
6. In patients with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy, is opioid-based therapy more effective than and as safe as no additional therapy?	In individuals with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy, we suggest that opioid-based therapy be considered for dyspnea management, within a personalized shared decision-making approach.	Conditional	Very low certainty

Definition of abbreviations: COPD = chronic obstructive pulmonary disease; ICS = inhaled corticosteroids; LABA = long-acting β₂-agonist; LAMA = long-acting muscarinic antagonist; PICO = Population, Intervention, Comparator, and Outcomes.