"With South Korea entering a super-aged society, the number of patients with chronic obstructive pulmonary disease (COPD) will continue to rise. As the population ages, early detection and treatment to prevent high-risk patients from worsening are critically important."

At the end of last year, the Korean COPD treatment guidelines were revised for the first time in six years, simplifying patient classification and adding blood eosinophil count criteria to treatment-strategy establishment.

The aim was to simplify the guidelines compared with the previous version, making treatment more straightforward in clinical practice. The initial treatment strategies now categorize patients into low-risk and high-risk groups.

Dr. Yong Bum Park, Professor of the Pulmonary Department at Kangdong Sacred Heart Hospital (chair of the COPD guidelines revision committee), emphasized the need for appropriate treatment approaches and policy improvements in response to the growing COPD patient population.

COPD is a condition in which abnormalities occur in the 'airways' necessary for breathing or in the alveoli at the lung periphery, influenced not only by smoking but also by indoor and outdoor air pollution, occupational hazards, and genetic factors.

Korea's National Health and Nutrition Examination Survey shows that approximately 13% of the population aged 40 and over has COPD. With an aging population, it is reported that one in two men aged 65 and above in Korea suffers from COPD.

Dr. Park explained, "Although COPD prevalence appears high at 12%, according to Health Insurance Review & Assessment Service (HIRA) criteria, at most 5% have been diagnosed with COPD, and of those, fewer than 2% are registered as patients and managed in hospitals."

Therefore, the most critical aspect of COPD treatment is early diagnosis. For this reason, the Korean Academy of Tuberculosis and Respiratory Diseases has proposed to the government that pulmonary function testing be included in the national health screening program.

It has been pointed out that if treatment is initiated at an advanced stage of the disease, more medications will be required, increasing not only the individual burden due to exacerbations but also the overall national burden. In fact, a domestic study estimated the socio-economic burden of COPD patients at approximately KRW 1.4 trillion.

Dr. Park said, "The socio-economic burden reaches about KRW 1.4 trillion for patients receiving care in hospitals alone, which is a substantial burden. I believe it is crucial to detect these patients early."

Even though COPD carries a significant socio-economic burden once diagnosed, the general public remains poorly informed about the disease, making early diagnosis through national screening necessary.

Dr. Park emphasized, "If pulmonary function testing were implemented as part of the national health screening, it would detect COPD and all conditions associated with impaired lung function, such as asthma or pulmonary fibrosis. With early diagnosis, patients with symptoms can receive pharmacotherapy or preventive measures, such as vaccinations, management of risk factors like smoking, and rehabilitation through exercise, to halt disease progression and exacerbations."

Guidelines for COPD treatment were revised after six years…has been simplified categorizing patients from three patient groups to low-risk‧high-risk patient groups

Not only in Korean but also in global COPD guidelines, pulmonary function testing is specified as essential for diagnosis.

In December 2024, the domestic COPD guidelines were revised for the first time in six years, simplifying patient classification and adding a blood eosinophil count criterion to inform treatment strategy for promptly managing diagnosed patients.

While the previous 2018 guidelines classified COPD patients into three groups based on FEV1 (forced expiratory volume in one second), number of exacerbations in the past year, the mMRC dyspnea scale, and the COPD Assessment Test (CAT), the revised guidelines now categorize patients into only two risk categories, high-risk and low-risk, based solely on the number of exacerbations in the past year.

Dr. Park explained, "Over the past 3-4 years, combination therapy with LABA+LAMA is superior to LABA or LAMA monotherapy in terms of quality of life, lung function, symptom improvement, and reduction in exacerbation frequency, reducing the need for multiple low-risk subgroups. Therefore, patients are now categorized into high-risk and low-risk groups, and the initial treatment strategies have been updated accordingly."

Although the guideline revision is intuitive, key points are worth highlighting. The revised guidance identifies exacerbation history as a crucial variable and incorporates a blood eosinophil count criterion for medications.

As a result, for high-risk patients, if the blood eosinophil count is below 300 cells/㎣, LABA+LAMA combination therapy is recommended. If it is 300 cells/㎣ or higher, triple combination therapy with ICS+LAMA+LABA is advised.

Dr. Park noted, "Patients in the high-risk group with a blood eosinophil count of 300 cells per microliter or more are known to respond well to inhaled corticosteroids (ICS), so ICS use is recommended. Notably, triple combination therapy combining ICS+LAMA+LABA into a single inhaler has demonstrated efficacy in reducing mortality, improving lung function, and enhancing quality of life, which is why triple combination therapy is recommended for high-risk patients."

"Training is crucial for COPD inhaler treatment…Triple combination therapy offers better drug tolerance"

The most common COPD triple combination therapy is Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol).

In the IMPACT Phase 3 trial, triple combination therapy with Trelegy reduced the treatment risk of all-cause mortality by 42% compared with LAMA+LABA therapy.

In a post-hoc analysis, patients receiving Trelegy triple combination therapy experienced a 38% reduction in on-/off-treatment all-cause mortality risk compared with those on LAMA+LABA therapy.

Dr. Park mentioned, "Even in the overall trial results, about half of high-risk patients continue to experience symptoms, exacerbations, and dyspnea despite triple therapy," and added, "Nevertheless, compared with previous medications, the newer triple combination therapies, especially single-device formulations like Trelegy, are much more convenient for patients to use."

One of the key issues in COPD treatment is drug adherence. Unlike oral therapies for hypertension or diabetes, COPD treatment relies heavily on inhalers, making patient education and support more challenging. Moreover, improper inhaler technique can reduce efficacy, underscoring the importance of training.

Dr. Park said, "Previously, triple combination therapy required two separate inhalers, but now the advantage is that three medications can be delivered evenly through a single device. In patients who had used two devices or LABA+LAMA dual combination therapy, switching to triple therapy improved symptoms and reduced exacerbation rates."

Finally, Dr. Park again emphasized the importance of early diagnosis in a growing COPD patient population.

"In South Korea, only about 2-5% of patients are currently managed, while the remaining 95-98% are not even aware that they have COPD," Dr. Park added, "Once the disease progresses to severe stages and exacerbations begin, the socio-economic burden increases significantly, so we must establish methods for early COPD diagnosis."