<p>Bronchodilators are the hallmark of maintenance treatment for chronic obstructive pulmonary disease (COPD). Recommendations from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2026 report can help clinicians choose appropriate treatment for their patients with COPD.</p>

COPD is a chronically symptomatic disease, with bronchodilator therapy reflecting the hallmark of maintenance treatment. The GOLD Science Committee has revised its therapeutic recommendations to optimize therapies geared toward achieving ideal outcomes for an individual patient. In the latest iteration, this group recommends the use of a bronchodilator in a patient with established COPD who has minimal symptoms and no exacerbation risk. This includes either a short- or long-acting bronchodilator, the latter of which is the preferred choice (if available). This recommendation generally aligns with what is done in the primary care setting, where patients with milder COPD are typically cared for. When patients with COPD experience more regular symptoms, ideally quantified with an instrument such as the Modified Medical Research Council (mMRC) Dyspnea Scale or the COPD Assessment Test (CAT), the recommendation escalates to the use of a long-acting bronchodilator. This recommendation is based on numerous studies confirming that long-acting bronchodilators provide symptomatic control and long-acting bronchodilation. As such, GOLD recommends that, for a person with COPD with an mMRC Dyspnea Scale score of 2 or higher or a CAT score of 10 or higher, clinicians should consider using a long-acting bronchodilator.

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A key prospective study clarified the question regarding whether a single long-acting bronchodilator or the combination of a LABA plus a LAMA should be considered. The EMAX trial randomized symptomatic patients with COPD (CAT score, ≥10) at low risk of exacerbation who had not been using an inhaled corticosteroid in the prior 6 weeks to LABA, LAMA, or LABA-plus-LAMA therapy. Combination therapy was superior to the individual agents in lung function improvement over 24 weeks, the primary end point. Importantly, dyspnea improvement also favored dual-agent therapy. This benefit was noted across patients with a wide range of baseline symptomatic burden.

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These data were influential in GOLD recommending that dual bronchodilation be considered initially in a patient with COPD who has greater symptomatic burden. As patients are followed over time, if breathlessness persists, GOLD recommends that individuals on a single long-acting bronchodilator be transitioned to dual therapy with an additional assessment of inhaler device use and educational strategies to improve the breathlessness, be introduced to nonpharmacologic therapies (including pulmonary rehabilitation), and be investigated for alternate causes of breathlessness.

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For patients at higher risk for an exacerbation, dual bronchodilation has also been recommended over individual agents based on prior comparative studies. Several years before this, the GOLD Science Committee transitioned to recommending dual bronchodilation in a fixed device (if available) for symptomatic patients to maximize adherence.

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In deciding the ideal treatment for an individual patient with COPD, multiple factors need to be considered, including those that are patient related, treatment related, and socioeconomic related in nature. The former includes patient forgetfulness, unclear disease understanding, depression, the influence of comorbidities, and substance use. Complex medication regimens, dosing frequency, tolerability, and difficulty with using the inhaler device also influence adherence. Similarly, financial burden and access to medications have a major influence on medication access. This further complicates treatment.

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The GOLD schema has gradually evolved to a patient-centered approach that attempts to provide the pharmacotherapy that is most likely to improve patient outcomes. It provides a holistically comprehensive approach to following personalized therapy principles.