We have read with special interest the article by Miravitlles et al. in which a simple algorithm is proposed for the initial treatment of chronic obstructive pulmonary disease (COPD) based on the GOLD ABE proposal.1 Following the GOLD 2023 scheme, the indication for triple therapy with LAMA-LABA-ICS (LAMA: long-acting muscarinic antagonist; LABA: long-acting β2-agonist; ICS: inhaled corticosteroid) as initial therapy in the exacerbator patient (patients with ≥2 moderate exacerbations or ≥1 exacerbation leading to hospitalization) will depend on the degree of peripheral eosinophilia (greater than 300cells per μL) without taking into account the exacerbation severity. Both scenarios (COPD exacerbation requiring hospital admission and frequent exacerbations with outpatient management) have shown to have short, medium and long-term clinical implications including accelerated loss of lung function, poor long-term survival, high impact on health status, development of cardiovascular events and increase in healthcare costs. However, these aspects are especially critical in those exacerbations that require hospital management.

According to data extracted from the AUDIPOC study, up to 35% of COPD patients admitted for an exacerbation are readmitted after 90 days,2 which reflects the difficulty in controlling these events and the need to optimize treatment upon discharge. On the other hand, start maintenance inhaled therapy for the first time after a severe exacerbation is not an uncommon situation. In a study carried out by Balcells et al.3 in which characteristics of patients with COPD who were admitted for the first time due to an exacerbation were analyzed, it was described that around 40% of them did not receive prior inhaled treatment. In this context, the treatment prescribed at discharge would be considered as “initial therapy” according to the GOLD 2023 guideline. To date, multiple studies support the role of inhaled corticosteroids in preventing exacerbations. A post hoc analysis of the IMPACT study demonstrates that the initiation of LAMA-LABA-ICS triple therapy after a severe COPD exacerbation provides a greater benefit in terms of the development of future exacerbations than LAMA-LABA therapy in those patients with a level of eosinophils in peripheral blood>100cells per μL.4 Added to these results are those presented in the PRIMUS study, which describes that early initiation of triple therapy after a severe exacerbation is associated with lower morbidity and economic burden. Based on all this, the recent publication of the document “Referral criteria in COPD. Continuity of care”,5 proposes anticipating the prescription of LAMA-LABA-ICS as initial therapy in subjects with a severe exacerbation of COPD who present an eosinophil count in peripheral blood greater than 100cells per μL (Fig. 1).5 This approach is intended to maximize treatment and thus avoid future adverse events.

Fig. 1.

Proposal for initial pharmacological treatment. Low risk: Patients who present mild or moderate airflow obstruction, low degree of dyspnea (mMRC of 0–1) and ≤1 exacerbation that has not required admission (all criteria must be met). High risk: Patients who present severe or very severe airflow obstruction, a high degree of dyspnea (mMRC≥2) and/or at least ≥2 moderate exacerbations in the previous year or at least 1 that required hospital admission (at least 1 criterion must be met). Abbreviations: LAMA: long-acting muscarinic antagonist; LABA: long-acting β2-agonist; ICS: inhaled corticosteroid; Eo: eosinophils.

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