Chronic Obstructive Pulmonary Disease (COPD)
The pathways in this section refer to the GOLD Guidelines. This means that pathways (GOLD A, B, E) are not a stepwise progression, but intended as a guide for initiation of the pharmacological management of COPD according to the individual patient assessment of symptoms and exacerbation risk following the ABE scheme. Following reclassification of GOLD guidelines in 2023, patients historically prescribed monotherapy bronchodilators should be reviewed accordingly.
As part of NHS Scotland’s commitment to greener health care, the environmental impact of inhalers has been taken into account whilst developing the regional formulary. The West of Scotland Formulary encourages prescribers to base the choice of inhaler(s) for COPD on an assessment of correct technique, the preference of the person receiving the treatment, the lowest environmental impact among suitable devices and the presence of an integral dose counter.
A diagnosis of COPD must be made using spirometry. The presence of non-fully reversible airflow limitation (i.e. FEV1/FVC < 0.7 post-bronchodilation) measured by spirometry is mandatory to establish the diagnosis of COPD.
GOLD COPD website Quality Prescribing Strategy: Respiratory (2024-27) Asthma and Lung UK: Inhaler videos RightBreathe website
Prescribing Notes:
- Best practice is to prescribe all inhalers by brand name and device type, specifying strength and dose.
- Assessment of a patient’s inhaler technique is required before an inhaler is prescribed as this will determine the choice of product. Information on assessing inhaler technique and counselling on the correct method can be found at the Asthma and Lung UK inhaler technique videos.
- Regularly checking inhaler technique is recommended to ensure patients are still able to use the device prescribed.
- All inhalers have different ‘in use’ expiry, this can lead to unintended wastage. Ensure patients are given adequate advice on effective use of the device. For example, an inhaler with an in-use expiry of 6 weeks: one inhaler lasts 1 month with regular use. If 2 inhalers are prescribed and dispensed and both opened at the same time, they will both expire 6 weeks later, but if opened one at a time they would have lasted 2 months.
- Inhaler-induced cough by MDI may be alleviated by use of a spacer or change of device.
- Not all spacers are compatible with all inhalers; users should seek advice from their local pharmacist regarding the appropriate spacer to be used. Please refer to the RightBreathe website for guidance on compatibility and training material.
History Notes
15/04/2026
Regional formulary chapter launched.
Bronchodilator options for 0 or 1 moderate exacerbations (no hospital admissions) and mMRC 0-1, CAT <10.
SABA Dry Powder Inhaler – Easyhaler Salbutamol or Metered Dose Inhaler – Salbutamol.
LAMA Soft Mist Inhaler – Spiriva Respimat.
When the patient has used an inhaler with 6 cartridges, prescribe a new Spiriva Respimat pack containing an inhaler. Do not use the Respimat re-usable inhaler for more than one year, after having inserted the first cartridge.
Prescribing Notes:
- There is virtually no difference in efficacy between salbutamol and terbutaline; currently salbutamol is less expensive and available in a wider range of devices.
History Notes
20/07/2026
Information note for Tiotropium (Spiriva Respimat) updated for consistency.
15/04/2026
Regional formulary chapter launched.
LAMA/LABA (Long-Acting Muscarinic Antagonist/Long Acting Beta2 Agonist) options for 0 or 1 moderate exacerbations (no hospital admissions) and mMRC ≥ 2, CAT ≥10.
LAMA/LABA Dry Powder Inhaler – Anoro Ellipta.
LAMA/LABA Soft Mist Inhaler – Spiolto Respimat.
When the patient has used an inhaler with 6 cartridges, prescribe a new Spiolto Respimat pack containing an inhaler. Do not use the Respimat re-usable inhaler for more than one year, after having inserted the first cartridge.
LAMA/LABA Metered Dose Inhaler – Bevespi Aerosphere.
Prescribing Notes:
- Before prescribing a Respimat device please ensure patient can load and activate the device.
- For patients with persistent breathlessness or exercise limitation on bronchodilator monotherapy, the use of LAMA/LABA is recommended.
- Following GOLD guideline reclassification, it is recommended that patients on historical monotherapy should be reviewed as appropriate.
History Notes
15/04/2026
Regional formulary chapter launched.
LAMA/LABA (Long-Acting Muscarinic Antagonist/Long Acting Beta2 Agonist) options for ≥2 moderate exacerbations (or ≥1 leading to hospital admission) in the past year.
LAMA/LABA Dry Powder Inhaler – Anoro Ellipta.
LAMA/LABA Soft Mist Inhaler – Spiolto Respimat.
When the patient has used an inhaler with 6 cartridges, prescribe a new Spiolto Respimat pack containing an inhaler. Do not use the Respimat re-usable inhaler for more than one year, after having inserted the first cartridge.
LAMA/LABA Metered dose Inhaler – Bevespi Aerosphere.
LABA/LAMA/ICS (Long Acting Beta2 Agonist/ Long-Acting Muscarinic Antagonist/ Inhaled Corticosteroid Combination) options for ≥2 moderate exacerbations (or ≥1 leading to hospital admission) if blood eosinophils ≥300 cells/microlitre.
LABA/LAMA/ICS Dry Powder Inhaler – Trelegy Ellipta.
LABA/LAMA/ICS Metered Dose Inhaler – Trixeo Aerosphere.
LABA/LAMA/ICS Dry Powder Inhaler – Trimbow NEXThaler.
Prescribing Notes:
- Before prescribing a Respimat device please ensure patient can load and activate the device.
- Combination products can be a cost-effective alternative to the individual products and are more convenient to use. Choice will depend on the selected inhaled steroid and inhaler technique.
- If patients with COPD have concomitant asthma, they should be treated like patients with asthma. Refer to Asthma pathways. Under these circumstances the use of an ICS is mandatory.
- Blood eosinophil counts may identify patients with a greater likelihood of a beneficial response to ICS. For patients who develop exacerbations with a blood eosinophil count ≥ 300 cells/µL, escalation to LABA+LAMA+ICS may be considered.
- Withdrawing ICS should be considered if pneumonia or other considerable side-effects develop.
- See the Healthcare Improvement Scotland website for details around the use of a Steroid Emergency Card.
History Notes
15/04/2026
Regional formulary chapter launched.
Prescribing Notes:
- Prescribing of azithromycin should be on the advice of a respiratory specialist, following sensitivities and investigations in secondary care.
- The use of azithromycin is for both its antibiotic and anti-inflammatory properties.
History Notes
15/04/2026
Regional formulary chapter launched.
Prescribing Notes:
- A 4-week trial of a mucolytic agent should be considered in COPD patients chronically troubled by sputum production. Only continue if symptoms improve.
- Ensure the most cost-effective brand of acetylcisteine is chosen in line with individual health Board preference.
- The dose of carbocisteine can be reduced as the condition improves.
History Notes
15/04/2026
Regional formulary chapter launched.
Prednisolone with or without an antibiotic (amoxicillin or doxycycline).
30mg once daily for 5 days.
500mg three times a day for 5 days, increased if necessary to 1g three times a day.
Initially 200mg for 1 dose on first day, then 100mg once daily for 5 days in total, dose can be increased if necessary to 200mg once daily in severe infections.
Consider an alternative antibiotic (amoxicillin or doxycycline) that wasn’t used as first choice.
Prescribing Notes:
- The regional formulary will not cover all eventualities for infections medicines choices. As with any condition; patient specific factors and sensitivities need to be considered. Please consider this regional formulary advice alongside any relevant local Board guidelines.
- The vast majority of respiratory tract illness is self-limiting, and it is recommended that the term “infection” is avoided. Purulent sputum alone is not a marker for antibiotic treatment.
- Antibiotics are only indicated in acute exacerbations of COPD when purulent sputum and increased breathlessness and/or increased sputum volume are present.
- Risk factors for antibiotic resistant organisms include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in the last three months. Consider sending a sputum sample +/- chest X-ray to assess if consolidation present.
- Co-trimoxazole may be considered for use particularly in individuals who have received multiple courses of antibiotics, the elderly, those at risk of Clostridium difficile infection and have persistent symptoms of infection despite first line antibiotics. Send sputum for culture and consider a CXR.
- Patients on high doses of steroids who receive more than three to four courses of oral steroids per year should be considered for bone protection. See osteoporosis recommendations in the Endocrine chapter of the formulary. See the Healthcare Improvement Scotland website for details around the use of a Steroid Emergency Card.
- Euphoria is a recognised adverse effect of prednisolone – prescribers should be alert to the possibility of this effect driving some treatment requests.
- Where laboratory susceptibility reports recommend that increased dosing is required for specific antimicrobials in relation to organism susceptibility, please refer to local guidelines.
History Notes
30/07/2026
Pathway added following the launch of the Infections chapter.
Prescribing Notes:
- Nebulisers are not currently prescribable in general practice, however the nebules used within them are. Patients should be referred for respiratory assessment and if suitable they will be leased a machine. A spacer should be tried before considering a nebuliser.
History Notes
15/04/2026
Regional formulary chapter launched.
Nebulisers should only be used in patients with an FEV1<50% and on maximum inhaled therapy under care of a respiratory specialist.
Prescribing Notes:
- Nebulisers are not currently prescribable in general practice however the nebules used within them are. Patients should be referred for respiratory assessment and if suitable they will be leased a machine. A spacer should be tried before considering a nebuliser.
- All nebulisers should be serviced regularly. However, difficulties are often encountered in the servicing of privately owned nebulisers. Patients should be discouraged from buying a nebuliser.
History Notes
15/04/2026
Regional formulary chapter launched.
Prescribing Notes:
- Not all spacers are compatible with all inhalers; users should seek advice from their local pharmacist regarding the appropriate spacer to be used. Please refer to the RightBreathe website for guidance on compatibility and training material.
- The Asthma+Lung UK website provides guidance on different breathing techniques with a spacer – the single breath and hold technique, or the tidal/multiple breath technique.
- Spacers should be cleaned no more than weekly, with water and washing-up liquid, or put in a dishwasher, and allowed to air dry. More frequent cleaning affects their performance due to build-up of static.
- AeroChamber Plus Flow-Vu and Volumatic should be replaced every 12 months following regular use.
History Notes
15/04/2026
Regional formulary chapter launched.