Chronic obstructive pulmonary disease (COPD) affects an estimated 1.2 million diagnosed patients in England, with a similar number believed to be undiagnosed, according to the British Lung Foundation. It is the third leading cause of death worldwide and a major driver of NHS hospital admissions — particularly during winter months. Community pharmacists dispense COPD medicines daily and are well placed to optimise therapy, check inhaler technique and recognise early signs of exacerbation.

The NICE stepwise approach to COPD inhalers

NICE guideline NG115 (Chronic obstructive pulmonary disease in over 16s) sets out a stepwise inhaler pathway that pharmacy teams should understand:

Step 1: Short-acting bronchodilators

All COPD patients should have access to a short-acting bronchodilator (SABA or SAMA) for symptom relief. Salbutamol (SABA) or ipratropium (SAMA) are used as needed.

Step 2: Long-acting bronchodilators

When symptoms are not adequately controlled by short-acting agents, a long-acting bronchodilator is added:

• LABA (long-acting beta-2 agonist): formoterol, salmeterol, indacaterol, olodaterol
• LAMA (long-acting muscarinic antagonist): tiotropium, glycopyrronium, umeclidinium, aclidinium

NICE recommends offering a LABA + LAMA combination if the patient remains symptomatic on monotherapy, unless features suggest asthma-COPD overlap.

Step 3: Triple therapy

For patients with persistent breathlessness or frequent exacerbations despite LABA + LAMA, an inhaled corticosteroid (ICS) is added — creating "triple therapy" (ICS + LABA + LAMA). Single-device triple therapy inhalers are now available:

Single-device triple therapy simplifies regimens and may improve adherence compared with multiple inhalers. Pharmacists should be alert to patients using two or three separate inhalers who might benefit from consolidation — though the prescribing decision rests with the GP or respiratory team.

ICS appropriateness

Unlike in asthma, ICS use in COPD is more selective. NICE recommends ICS-containing regimens primarily for patients with features suggesting asthma-COPD overlap or those with frequent exacerbations (two or more per year, or one requiring hospitalisation). The eosinophil count guides this decision: ICS is more likely to be beneficial when blood eosinophils are 300 cells/microlitre or above.

Pharmacy teams should be aware that ICS in COPD increases the risk of pneumonia — a well-established class effect confirmed in the TORCH, INSPIRE and IMPACT trials. If a patient on an ICS-containing COPD regimen develops recurrent lower respiratory tract infections, flagging this to the prescriber is appropriate.

Inhaler technique in COPD

The principles of inhaler technique review are the same as for asthma (see: Asthma Inhaler Technique), with one important difference: many COPD patients have reduced inspiratory flow rates, which affects device choice.

DPIs require adequate inspiratory effort. Patients with severe COPD (FEV1 below 30% predicted) may not generate sufficient flow to use a DPI effectively. For these patients, a soft mist inhaler (Respimat) or MDI with spacer may be more appropriate.

Check technique at every dispensing. The NRAD recommendation to check technique at every opportunity applies equally to COPD. Given that COPD patients are often older and may have comorbidities affecting dexterity and cognition, technique errors are common and recurrent.

Exacerbation recognition and rescue packs

An exacerbation of COPD is defined as an acute worsening of symptoms beyond normal day-to-day variation that requires a change in medication. Exacerbations are a leading cause of hospitalisation and are associated with accelerated lung function decline.

Many COPD patients hold a rescue pack — typically a short course of prednisolone (30mg daily for 5 days) and/or an antibiotic (usually amoxicillin or doxycycline) — to start at the onset of an exacerbation, with instructions from their GP or respiratory team.

Pharmacy role in exacerbations:

• Recognise early signs. Increased breathlessness, increased sputum volume or purulence, and increased cough are the cardinal signs. Patients collecting a rescue pack should be asked about their symptoms.
• Check rescue pack stock. When dispensing a rescue pack, note the date and advise the patient to request a replacement from their GP. Patients who use rescue packs frequently (three or more per year) should be referred for specialist review.
• Emergency referral. Refer urgently (call 999 or direct to A&E) if the patient shows signs of severe exacerbation: cyanosis, confusion, peripheral oedema, inability to speak in sentences, respiratory rate above 25, or oxygen saturation below 92% on pulse oximetry (if available in the pharmacy).

Smoking cessation: the most important intervention

Smoking cessation is the single most effective intervention to slow COPD progression. It is the only intervention proven to reduce the rate of lung function decline. Community pharmacy stop smoking services are a critical part of COPD management.

Pharmacists should ask about smoking status at every COPD-related dispensing interaction and offer brief advice: "The best thing you can do for your COPD is to stop smoking — would you like help with that?" This takes less than 30 seconds and is supported by strong evidence for effectiveness.

Comorbidity awareness

COPD rarely occurs in isolation. Common comorbidities include:

• Cardiovascular disease — the leading cause of death in mild-to-moderate COPD
• Anxiety and depression — affecting up to 40% of COPD patients
• Osteoporosis — exacerbated by long-term oral corticosteroid use and physical inactivity
• Type 2 diabetes — prevalence is higher in COPD populations (see: Type 2 Diabetes Pharmacy Management)

Pharmacy structured medication reviews and NMS consultations provide natural opportunities to screen for undertreated comorbidities.

Pharmacists with respiratory or chronic disease interests can explore specialist and clinical roles through PharmSee's job search, where NHS trust and PCN respiratory pharmacist posts are regularly listed.

Sources

• NICE NG115: Chronic obstructive pulmonary disease in over 16s (updated 2024).
• GOLD 2024: Global Strategy for the Diagnosis, Management, and Prevention of COPD.
• British Lung Foundation. COPD statistics, 2024.
• IMPACT trial: Lipson DA et al. NEJM, 2018.
• PharmSee pharmacy data: pharmsee.co.uk.