Key points
- GOLD advises that everyone with COPD is prescribed a short-acting bronchodilator reliever, such as salbutamol (albuterol), for immediate relief.
- GOLD 2026 recommends a combined long-acting beta-agonist and long-acting antimuscarinic (LABA+LAMA) as the first maintenance treatment for most people with frequent symptoms or flare-ups.
- An inhaled corticosteroid (ICS) is added mainly for people with flare-ups and a blood eosinophil count of at least 300 cells/µL (or at least 100 cells/µL after flare-ups on LABA+LAMA). ICS raise the risk of pneumonia.
- More than two-thirds of people make at least one error with their inhaler. Technique should be shown, checked and corrected at every review.
- Stop-smoking medicines (varenicline, bupropion, nicotine replacement) increase quit rates. The FDA removed varenicline's boxed warning for mental health effects in December 2016.
The inhaler classes
- SABA (short-acting beta2-agonist, such as salbutamol): opens the airways. WHO notes that short-acting bronchodilators start to work in seconds and last 4 to 6 hours. Used for relief and during flare-ups.
- LABA (long-acting beta2-agonist, such as salmeterol, formoterol or vilanterol): a long-acting airway opener for daily maintenance.
- LAMA (long-acting muscarinic antagonist, such as tiotropium or umeclidinium): a different long-acting airway opener. The tiotropium label describes it as once-daily maintenance, not a rescue medicine.
- ICS (inhaled corticosteroid, such as fluticasone or budesonide): reduces airway inflammation. In COPD, GOLD uses it combined with LABA+LAMA rather than with a LABA alone.
What GOLD 2026 recommends
GOLD groups people by symptoms and flare-up history. Group A has fewer symptoms, Group B more symptoms, and Group E a history of exacerbations. In 2026 GOLD adjusted the groups so that even one moderate exacerbation counts.
- Group A: a bronchodilator, preferably long-acting if available and affordable, continued if it helps.
- Group B: start LABA+LAMA. If a combination is not appropriate, either a LABA or a LAMA alone.
- Group E: start LABA+LAMA. Consider triple therapy (LABA+LAMA+ICS) from the start if blood eosinophils are 300 cells/µL or more. GOLD does not encourage LABA+ICS for COPD. If an ICS is needed, triple therapy is preferred.
- COPD with asthma: treat as asthma. An ICS is then essential.
Follow-up (GOLD Figure 3.9):
- Persistent breathlessness on one long-acting bronchodilator: move to LABA+LAMA. If still breathless, check the device and technique, add pulmonary rehabilitation, consider ensifentrine where available, and look for other causes.
- One or more moderate or severe flare-ups on LABA+LAMA: add an ICS if eosinophils are 100 cells/µL or more. A greater benefit is more likely with higher counts.
- Continued flare-ups: consider roflumilast (FEV1 below 50% with chronic bronchitis), azithromycin (preferably in people who no longer smoke, bearing in mind antibiotic resistance), or a biologic if eosinophils are 300 cells/µL or more. The biologics are dupilumab (if chronic bronchitis is present) and mepolizumab.
- Do not stop an ICS that is working unless there is pneumonia or another significant side effect. Flare-ups are more likely after stopping it if eosinophils are 300 cells/µL or more.
Single inhalers that combine medicines may be more convenient and improve adherence.
Newer COPD medicines
- Ensifentrine (a dual PDE3 and PDE4 inhibitor, 3 mg twice daily by jet nebuliser): FDA-approved in June 2024 for COPD maintenance in adults. GOLD notes it improves lung function and breathlessness but is currently available only in the US.
- Dupilumab: FDA-approved for COPD in September 2024, and mepolizumab in May 2025. Both are injections, approved as add-on maintenance for adults with inadequately controlled COPD and an eosinophilic phenotype.
Inhaler technique
- GOLD reports that more than two-thirds of patients make at least one error. Common errors involve how hard and how long to breathe in, coordination, preparing the dose, breathing out first, and holding the breath afterwards.
- Pressurised inhalers (pMDI) and soft-mist inhalers need a slow, deep breath in. Dry-powder inhalers need a forceful breath in. If someone cannot inhale forcefully, switch to a pMDI with spacer or a soft-mist inhaler.
- Use a spacer if there is any doubt about pMDI technique. Spacers also reduce steroid deposited in the mouth.
- Package leaflets alone are not enough. Ask the person to show how they use the device ("teach-back") and recheck regularly. Technique problems are more common in older adults, mainly because of reduced dexterity or cognition.
- Rinse the mouth with water and spit after an ICS-containing inhaler to reduce oral thrush.
Smoking-cessation medicines
GOLD advises that everyone who smokes should be strongly encouraged and supported to quit, and that medicines and counselling reliably increase long-term quit rates. In smokers with COPD, prolonged abstinence with medicines ranged from 14% to 27%, compared with 5% to 9% on placebo. GOLD states there is not yet enough evidence to recommend e-cigarettes as a quitting aid.
- Varenicline: start 1 week before the quit date (or quit between days 8 and 35). Increase from 0.5 mg daily to 1 mg twice daily for 12 weeks, with another 12 weeks for those who have quit. The FDA removed its boxed warning in December 2016 after a large safety trial. The label still warns about mood and behaviour changes, seizures, stronger effects of alcohol, accidental injury, sleepwalking, and possible cardiovascular events in people with heart disease. Reduce the dose in severe kidney impairment (creatinine clearance below 30 mL/min).
- Bupropion SR: start 1 week before quitting, 150 mg daily for 3 days and then 150 mg twice daily, at least 8 hours apart. Do not use with seizure disorders, current or past eating disorders, abrupt withdrawal from alcohol or sedatives, or with MAO inhibitors. Lower doses are needed in liver impairment. It carries the antidepressant boxed warning on suicidal thoughts in children, adolescents and young adults.
- Nicotine replacement (patch, gum, lozenge, inhaler, nasal spray, sublingual tablet): GOLD lists recent heart attack or stroke as contraindications, and notes evidence that it can be started more than 2 weeks after a cardiovascular event. Site irritation is common. The patch label advises asking a doctor first with heart disease, irregular heartbeat, uncontrolled blood pressure, stomach ulcer, diabetes or seizures. In pregnancy or breastfeeding, use only on a clinician's advice. The bupropion label notes it may be used with a nicotine patch.
Safety: what to check
- Relievers are not a substitute for maintenance treatment. Needing more relief doses than usual is a sign of deterioration. Excessive SABA use can be dangerous. LAMA, LABA and ensifentrine are not for acute symptoms.
- Do not double up long-acting beta-agonists (for example, two inhalers that both contain a LABA), because of overdose risk.
- Beta-agonists: palpitations, tremor, low potassium and raised blood glucose can occur. Use with caution in heart disease and seizure disorders, and with QT-prolonging drugs or non-potassium-sparing diuretics.
- LAMAs: can worsen narrow-angle glaucoma and urinary retention. Use with caution with an enlarged prostate or bladder-neck obstruction, and get help urgently for eye pain, blurred vision or difficulty passing urine.
- ICS: pneumonia, oral thrush, hoarse voice and skin bruising. GOLD lists higher pneumonia risk in people who smoke, are aged 55 or over, have had previous exacerbations or pneumonia, have a BMI below 25, more breathlessness or severe airflow obstruction. Labels also list possible bone loss, glaucoma and cataracts with long-term use. Strong CYP3A4 inhibitors can increase steroid effects.
- Ensifentrine: psychiatric effects including suicidality were reported. Weigh benefits and risks in people with a history of depression or suicidal thoughts.
- Kidneys, liver, pregnancy and older adults: varenicline needs a lower dose in severe kidney impairment and bupropion in liver impairment (see above). Nicotine replacement in pregnancy or breastfeeding should be used only on a clinician's advice. Inhaler errors are more common in older adults, so technique and device choice need extra checks. Discuss any inhaler use in pregnancy with the prescriber rather than stopping treatment.
- Paradoxical bronchospasm (sudden wheeze straight after a dose) can occur with any inhaler. Stop it and get help.
Frequently asked questions
Why am I not given a steroid inhaler for COPD?
GOLD prefers LABA+LAMA for most people. ICS adds a risk of pneumonia, and its benefit on flare-ups is linked to the blood eosinophil count, so it is added when flare-ups continue and the count suggests it will help.
Can I use my maintenance inhaler for sudden breathlessness?
No. Use your short-acting reliever and follow your action plan. If you need it much more than usual, contact your clinician.
Is varenicline safe if I have had depression?
Depression is not a contraindication on the US label, but the label advises watching for changes in mood or behaviour during a quit attempt. Stop it and contact a clinician if they occur.
Sources
- Global Initiative for Chronic Obstructive Lung Disease. 2026 GOLD Report. goldcopd.org
- World Health Organization. COPD fact sheet. who.int
- US FDA labels: albuterol HFA, tiotropium (Spiriva Respimat), fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta). albuterol, tiotropium, Trelegy
- US FDA labels: ensifentrine (Ohtuvayre), mepolizumab (Nucala). ensifentrine, mepolizumab
- US FDA labels: varenicline, bupropion SR, nicotine transdermal patch. varenicline, bupropion SR, nicotine patch
- US FDA. Chantix (varenicline) supplement approval package, 16 December 2016 (boxed warning removed). accessdata.fda.gov
- US FDA. Drugs@FDA approval history (ensifentrine, dupilumab, mepolizumab). accessdata.fda.gov
This article is for education and does not replace advice from a doctor, nurse or pharmacist who knows the person's history. Inhaler brands, devices and approvals differ between countries.
