{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T02:15:15Z","timestamp":1787019315337,"version":"build-2736575974"},"reference-count":104,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2023,1,1]],"date-time":"2023-01-01T00:00:00Z","timestamp":1672531200000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100001003","name":"Boehringer Ingelheim","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100001003","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Ther Adv Respir Dis"],"published-print":{"date-parts":[[2023,1]]},"abstract":"<jats:p>\n                    Inhaled bronchodilator therapy with long-acting muscarinic antagonists (LAMAs) and long-acting \u03b2\n                    <jats:sub>2<\/jats:sub>\n                    -agonists (LABAs) in combination is currently the mainstay of treatment for chronic obstructive pulmonary disease (COPD). Treatment guidelines recommend the addition of inhaled corticosteroids (ICS) to LABA\/LAMA only in patients with a history of frequent\/severe exacerbations and high blood eosinophil counts, or in those with concomitant asthma. Despite this, real-world data suggest that clinicians are not adhering to this guidance and that ICS are frequently overused. This is possibly due to the incorrect assumption that when LABA\/LAMA therapy is not sufficient, adding an ICS to the treatment regimen is the logical next step. In this narrative review, we describe global and country-specific guideline recommendations from Germany, Spain, and Japan and compare these with real-world data on LABA\/LAMA and ICS use in clinical practice. We also provide a clinical guide to the use of add-on therapies with LABA\/LAMA for different patient phenotypes, including (1) patients still symptomatic (but not exacerbating) despite LABA\/LAMA treatment; (2) patients still exacerbating despite LABA\/LAMA treatment who have high blood eosinophil counts; and (3) patients still exacerbating despite LABA\/LAMA treatment who do not have high blood eosinophils or concomitant asthma.\n                  <\/jats:p>","DOI":"10.1177\/17534666231208630","type":"journal-article","created":{"date-parts":[[2023,11,8]],"date-time":"2023-11-08T02:11:12Z","timestamp":1699409472000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":7,"title":["Stepwise management of COPD: What is next after bronchodilation?"],"prefix":"10.1177","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9850-9520","authenticated-orcid":false,"given":"Marc","family":"Miravitlles","sequence":"first","affiliation":[{"name":"Pneumology Department, University Hospital Vall d\u2032Hebron\/Vall d\u2019Hebron Research Institute (VHIR, Vall d\u2019Hebron Barcelona Hospital Campus; CIBER de Enfermedades Respiratorias [CIBERES]), P. 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