Deprecated function: Return type of DatabaseStatementBase::execute($args = [], $options = []) should either be compatible with PDOStatement::execute(?array $params = null): bool, or the #[\ReturnTypeWillChange] attribute should be used to temporarily suppress the notice in require_once() (line 2246 of /var/www/webmd/apps/mdedge/htdocs/includes/database/database.inc).
Deprecated function: Return type of DatabaseStatementEmpty::current() should either be compatible with Iterator::current(): mixed, or the #[\ReturnTypeWillChange] attribute should be used to temporarily suppress the notice in require_once() (line 2348 of /var/www/webmd/apps/mdedge/htdocs/includes/database/database.inc).
Deprecated function: Return type of DatabaseStatementEmpty::next() should either be compatible with Iterator::next(): void, or the #[\ReturnTypeWillChange] attribute should be used to temporarily suppress the notice in require_once() (line 2348 of /var/www/webmd/apps/mdedge/htdocs/includes/database/database.inc).
Deprecated function: Return type of DatabaseStatementEmpty::key() should either be compatible with Iterator::key(): mixed, or the #[\ReturnTypeWillChange] attribute should be used to temporarily suppress the notice in require_once() (line 2348 of /var/www/webmd/apps/mdedge/htdocs/includes/database/database.inc).
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Carl R. Darnall Army Medical Center, Uniformed Services University of the Health Sciences, Fort Hood, TX scalpelandyardstick@gmail.com
The authors reported no potential conflict of interest relevant to this article.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the US Army, Department of Defense, or the US Government.
Unclear what predominates? Follow the exacerbation predominance pathway.1
Additional decision-making might be necessary in several circumstances:
For the patient who requires further titration beyond these pathways, consider triple therapy as LABA + LAMA + ICS, unless the eosinophil count is < 100 cell/μL.1
Consider de-escalating ICS therapy if the patient develops pneumonia, there is a lack of demonstrated benefit, or the initial indication was uncertain or inappropriate.
For the patient who continues to have significant dyspnea despite dual or triple therapy, consider investigating and treating other causes of dyspnea.1
Last, keep in mind that evidence is limited regarding escalating the dosage of these agents (1) beyond what is listed in TABLE 21 and (2) in specific instances mentioned in the discussion of each inhaler class.
c Not an FDA-approved combination inhaled-agent treatment; approved in the European Union, under various brand names, by the European Medicines Agency.
c Not an FDA-approved combination inhaled-agent treatment; approved in the European Union, under various brand names, by the European Medicines Agency.
CORRESPONDENCE Michael Arnold, DO, FAAFP, Carl R. Darnall Army Medical Center, Uniformed Service University, 36065 Santa Fe Avenue, Fort Hood, TX 76544; scalpelandyardstick@gmail.com
