Update 2025 of the Spanish COPD Guidelines (GesEPOC): Pharmacological Treatment of Stable COPD

The Spanish COPD Guidelines (GesEPOC) were first published in 2012, and since then, several updates have incorporated new evidence regarding the diagnosis and treatment of COPD. GesEPOC is a clinical practice guideline developed with the collaboration of the scientific societies involved in COPD management and the Spanish Patients' Forum. Its recommendations are based on an evaluation of the evidence using the GRADE methodology and on a narrative description of the evidence in those areas where application of this methodology is not feasible. This article summarizes the updated recommendations on the pharmacological treatment of stable COPD, derived from the development of 12 PICO questions. The COPD treatment process comprises five stages: (1) diagnosis; (2) risk stratification; (3) characterization; (4) initiation and continuation of treatment; and (5) follow-up. For inhaled treatment selection, high-risk patients are classified into three phenotypes: non-exacerbator, eosinophilic exacerbator, and non-eosinophilic exacerbator. Treatable traits include general aspects, applicable to all patients-such as smoking cessation and inhaler technique-and more specific conditions, mainly affecting severe patients, such as chronic hypoxemia or chronic bronchial infection. The cornerstone of COPD treatment is long-acting bronchodilators, either as monotherapy or in combination, depending on the patient's risk level. Eosinophilic exacerbators should receive inhaled corticosteroids, whereas non-eosinophilic exacerbators require a detailed evaluation to identify the most appropriate therapeutic option. GesEPOC 2025 also includes recommendations on inhaled corticosteroid withdrawal, the introduction of biologics, and the indication for alpha-1 antitrypsin therapy. GesEPOC 2025 represents a more individualized approach to COPD treatment, tailored to the clinical characteristics of patients and their level of risk or complexity.