Table 1.

Recommendations for use of long-acting bronchodilators and/or ICS in patients with COPD

	Long-acting bronchodilators	ICS
GOLD 2021 [7]	Escalate LAMA or LABA monotherapy to LAMA/LABA for patients with dyspnea as the predominant trait Escalate LAMA or LABA monotherapy to LAMA/LABA for patients with exacerbations as the predominant trait, unless:  -Eosinophil levels are ≥ 300 cells/µl OR  -Eosinophils are ≥ 100 cells/µl and ≥ 2 moderate exacerbations (or ≥ 1 exacerbation leading to hospitalization) are experienced in the previous year	LABA/ICS should be considered if:  -Eosinophil levels are ≥ 300 cells/µl OR  -Eosinophils are ≥ 100 cells/µl and ≥ 2 moderate exacerbations (or ≥ 1 exacerbation leading to hospitalization) are experienced in the previous year For patients on LABA/ICS or LAMA/LABA/ICS, de-escalation of ICS or a switch to LAMA/LABA should be considered if there is a lack of response to ICS or if pneumonia develops
ATS [8]	Use LAMA/LABA over LAMA or LABA monotherapy in patients with COPD and dyspnea or exercise intolerance [strong recommendation]	Use triple therapy (LAMA/LABA/ICS) in patients with COPD and dyspnea or exercise intolerance (despite LAMA/LABA dual therapy) who have experienced ≥ 1 exacerbations in the past year [conditional recommendation] Consider ICS withdrawal for patients receiving triple therapy (LAMA/LABA/ICS) if no exacerbations in the past year [conditional recommendation]
NICE [10]	Offer LAMA/LABA to patients with COPD who:  -Do not have asthmatic features/features suggesting steroid responsiveness AND  -Remain breathless or have exacerbationsa	Consider LABA/ICS for patients with COPD who:  -Have asthmatic features/features suggesting steroid responsiveness AND  -Remain breathless or have exacerbationsa For patients with COPD who are taking LABA/ICS, offer LAMA/LABA/ICS if:  -Their day-to-day symptoms continue to adversely impact their quality of life OR  -They have a severe exacerbation (requiring hospitalization) OR  -They have two moderate exacerbations within a year For patients with COPD who are taking LAMA + LABA, consider LAMA + LABA + ICS if:  -They have a severe exacerbation (requiring hospitalization) OR  -They have two moderate exacerbations within a year
ERS [9]	N/A	Withdraw ICS in patients with COPD without a history of frequent exacerbations [conditional recommendation] Do not withdraw ICS in patients with blood eosinophil counts ≥ 300 eosinophils/µl [strong recommendation] Treat with one or two long-acting bronchodilators if ICS are withdrawn [strong recommendation]

ICS inhaled corticosteroids, LABA long-acting β₂-agonist, LAMA long-acting muscarinic antagonist, N/A not applicable

^aDespite having used or been offered treatment for tobacco dependence if they smoke AND optimized non-pharmacologic management and relevant vaccinations AND using a short-acting bronchodilator