Chronic Obstructive Pulmonary Disease in Singapore: Current Perspectives on Prevalence, Disease Burden, and Treatment

Introduction

Chronic obstructive pulmonary disease (COPD) is a complex, heterogeneous lung condition characterized by persistent and progressive airflow obstruction and chronic respiratory symptoms, resulting from abnormalities in both airways and alveoli.^1,2 COPD is a common respiratory condition in the Asia-Pacific region, including Singapore.³ However, the actual burden of the disease is likely underestimated due to underdiagnosis and undertreatment across many Asian countries.^3,4 This is largely attributed to insufficient disease awareness, limited access to diagnostic tools, and underutilization of pulmonary function tests.^3,4 The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2026 emphasizes the importance of early detection and appropriate assessment of the severity of COPD based on symptoms and lung function status.^1,5

Additionally, the misuse of inhalers and overreliance on oral corticosteroids (OCSs) are major therapeutic challenges. Such prescribing patterns are often driven by cost constraints, limited availability, and entrenched clinical practices. Environmental factors further complicate COPD management in Asia.⁴ Furthermore, the clinical profile of COPD in Asia is influenced by unique regional factors, such as a higher prevalence of bronchiectasis, tuberculosis-related lung damage, biomass smoke exposure, atopy, environmental fungal sensitization, and parasitic infections.^4,6,7 These characteristics necessitate management strategies tailored to the specific needs of Asian populations. The healthcare landscape of Singapore offers a unique opportunity to improve COPD management. This multiethnic nation, operating with a universal healthcare system, serves as a representative model for the Asian region.⁸ However, challenges in timely and accurate diagnosis persist and must be addressed to ensure appropriate and effective COPD management.

Current COPD management strategies combine essential non-pharmacological approaches (smoking cessation, pulmonary rehabilitation, and comorbidity management) with pharmacological interventions. Despite administration of a triple fixed dose of inhaled long-acting bronchodilators (long-acting β2-agonists [LABAs] and long-acting muscarinic antagonists [LAMAs]) along with inhaled corticosteroids (ICSs), many patients remain symptomatic and continue to face exacerbations.^1,9,10 OCSs are commonly used to treat COPD exacerbations; however, one in four patients was dispensed unsafe cumulative doses (≥1000 mg prednisolone-equivalent) within just 12 months, raising concerns about long-term adverse effects.¹¹ This persistent burden led to the investigation of biologic therapies targeting inflammatory pathways in COPD. Advances in the understanding of type 2 inflammation and epithelial alarmins have facilitated the clinical evaluation of monoclonal antibodies against tumor necrosis factor alpha and various interleukins (ILs), representing a promising therapeutic strategy under active investigation. Despite limited progress in COPD pharmacotherapy, dupilumab (anti-IL-4Rα) and mepolizumab (IL-5 antagonist) improve key outcomes in eosinophilic COPD, whereas other agents, such as tezepelumab, have shown minimal clinical benefit.^12,13

In Singapore, although COPD management has traditionally relied on bronchodilators and ICS, the treatment landscape is evolving. Dupilumab and mepolizumab are approved by the US Food and Drug Administration (US FDA) as an add-on maintenance treatment for adult patients with inadequately controlled COPD and an eosinophilic phenotype.^14,15 However, only dupilumab is available in Singapore as an add-on maintenance treatment for patients with uncontrolled COPD characterized by type 2 high inflammation, who are administered a stable combination of ICS, LABA, and LAMA, or LABA and LAMA if ICS is inappropriate.¹⁶ Ongoing clinical trials are investigating other biologics, such as benralizumab, itepekimab, tozorakimab, astegolimab, and tezepelumab, which target type 2 inflammation and alarmin pathways.¹⁷

This landscape review discusses the available evidence on COPD in Singapore, examining its epidemiology, clinical characteristics, disease progression patterns, treatment approaches, and outcomes. Focusing on the Singaporean context, we aim to provide healthcare professionals with relevant insights to optimize COPD management strategies and identify critical areas for future research and healthcare policy development for this high-burden disease.

Methods

We conducted a literature search to synthesize evidence on the epidemiology, risk factors, clinical characteristics, management, and healthcare burden of COPD in Singapore. A narrative approach was chosen to integrate the limited number of epidemiological and population-based studies from Singapore and the heterogeneous data sources. Literature search was based on keywords related to both COPD (“chronic obstructive pulmonary disease”, “COPD”, “chronic bronchitis”, “emphysema”) and geography (“Singapore”) and included all publications up to June 2025. Titles and abstracts were screened for relevance, followed by screening of full text. Articles related to the scope of the review were included in the narrative review and comprised of observational studies, clinical trials, registry analyses, population-based studies, real world evidence and health services of economic evaluations. Case reports were excluded. We further included literature from Singapore health agencies and additional relevant studies based on authors’ knowledge of published evidence.

Findings were synthesized qualitatively and organized into predefined domains: (1) prevalence, (2) demographic and clinical characteristics such as age, gender and ethnicity, (3) smoking patterns, (4) severity, (5) comorbidities, (6) disease burden, quality of life and economic costs, (7) hospitalization and morbidity burden, (8) evolution of COPD management in Singapore summarized based on real-world evidence, current treatment landscape and implementation of guidelines, (9) emerging therapeutic approaches and future directions, and (10) treatment adherence in patients with COPD from Singapore. Where relevant, Singapore data were contextualized against global literature.

Prevalence

In 2020, the estimated global prevalence of COPD was 10.6%, equating to 480 million affected people, with a projected increase to 592 million people by 2050.¹⁸ Considering the aging populations and neglect of key risk factors, patients are likely to face an increasing health burden. The rising prevalence of COPD will intensify the impact of the disease through significant healthcare costs for both patients and healthcare systems, resulting in a growing global economic burden.^1,19 In 2015, the overall estimated prevalence of COPD was 6.2% in the Asia-Pacific region and 5.9% specifically for Singapore.³ However, these figures may underestimate the actual burden of the disease as COPD remains considerably underdiagnosed and undertreated across many Asian countries. COPD is the fourth leading cause of death worldwide, resulting in 3.5 million deaths in 2021, ie, approximately 5% of all global deaths. COPD is the eighth leading cause of poor health worldwide as measured by disability-adjusted life years.²⁰

In 2023, COPD was the 10^th leading cause of death in Singapore.²¹ The burden of COPD in Singapore is expected to increase over time. By 2030, it is projected that one in four Singaporeans will be aged ≥65 years, potentially leading to a higher COPD prevalence.²² The Regional COPD Working Group reported that COPD affects approximately 3.5% of Singaporeans aged ≥30 years. However, this figure likely underestimates the actual prevalence because of underdiagnosis, particularly in early stages of the disease.^23,24

Overview of Clinical Studies

Epidemiological and population-based studies on COPD in Singapore are limited, posing a significant challenge to the accurate assessment of disease burden within the local population. To bridge this knowledge gap, we reviewed the limited number of available observational and real-world studies involving Singaporean patients with COPD. Although these studies primarily focused on treatment outcomes rather than epidemiological trends, they offer valuable insights into the demographic and clinical characteristics of Singaporean patients with COPD. Table 1 summarizes key research conducted on COPD in Singapore, highlighting study designs, patient populations, and primary research objectives.^3,25–30

Table 1 Summary of Key Studies on COPD in Singapore

Demographic and Clinical Characteristics

Age, Gender, and Ethnicity

Recent studies demonstrated a distinctive age distribution pattern among patients with COPD, with a mean age of >72 years, reflecting the predominantly elderly patient population.^27,29,30 However, the disease burden significantly affects the working-age population, with Lim et al reporting that approximately only 34% of patients with COPD were aged >65 years.³ A more detailed age stratification by George et al revealed increasing COPD prevalence with age, with 20.9% of patients affected in the 55–64 years age group, 29.6% in the 65–74 years age group, and 34.8% aged ≥75 years (Table 2).³¹ The substantial proportion of working-age patients with COPD suggests significant economic implications through productivity loss.

Table 2 Prevalence of COPD and Characteristics of Patients with COPD

A comprehensive meta-analysis of 194 studies revealed a global COPD prevalence of 9.23% in male patients and 6.16% in female patients, with a narrower gender gap in developed countries, wherein the prevalence in female patients almost matched that in male patients. COPD burden was particularly high in the Asian region, with the South-east Asian region showing the highest prevalence of 11.34% in male patients and 5.02% in female patients. However, there is a concerning lack of high-quality epidemiological data from this region;³³ therefore, current evidence from Singapore remained controversial.

Several cohort studies have consistently demonstrated a pronounced predominance among male patients with COPD. Sim et al reported that 91.6% of patients were male, while Alsuwaigh et al and George et al observed similar trends, with 91% and 89% male representation, respectively.^27–29 Yii et al provided additional evidence of predominance in male patients, reporting rates of 87.4% and 91.7% male representation in 2023 and 2025, respectively.^25,26 However, Lim et al observed a more balanced distribution, with 59% of patients being female.³ Moreover, the COPD Gene study revealed notable gender-related and age-related differences in COPD presentation and outcomes. Female patients demonstrated a concerning pattern of increased vulnerability, with a higher prevalence of early onset COPD (66% female predominance in patients aged <55 years), more severe dyspnea and airflow limitation, and 1.53 fold higher odds of exacerbations compared to male patients.³⁴ Further evidence is required to understand potential factors leading to gender imbalance in COPD prevalence.

The ethnic composition of patients with COPD in Singapore, as demonstrated in five recent studies,^25–29 reflects multicultural demographics while highlighting important considerations for clinical practice. The ethnic distribution across these five studies showed a consistent pattern, with Chinese participants comprising the majority in all investigations. The proportion of Chinese participants ranged from 52.9% to 76.4%. Malay participants constituted the second-largest ethnic group across all studies, with proportions ranging from 13.3% to 28.4%.^27,28 Indian participants represented a smaller proportion, ranging from 6.0% to 9.7% across these single-center studies.^25–29 The detailed ethnic distribution data are illustrated in Figure 1. The consistent representation of multiple ethnic groups across these studies emphasizes the need for culturally sensitive healthcare delivery in the COPD management framework of Singapore. The demographic findings from observational studies in clinical cohorts align closely with the results from the Singapore’s national health administrative databases.³⁵ Two cohorts were created retrospectively from this database for asthma and COPD patients followed from their index date to the earliest occurring event: death, loss to follow-up or the study end date of December 31, 2019. In the COPD cohort, patients had a mean age of 68.7 (SD 11.2) years, and were predominantly male population (82.9%) with 80.4% of the patients being of Chinese ethnicity followed by Malay (10.2%), Indian (5.4%) and others (4.0%).³⁵ This ethnic distribution is consistent with the racial composition of the Singapore resident population as reported in the 2020 consensus of Singapore population.³⁶

Figure 1 Ethnic distribution of patients with COPD in Singapore. Abbreviation: COPD, chronic obstructive pulmonary disease.

While we see differences in ethnic distribution of COPD, it is important to note that factors like particulate matter pollution, smoking, and occupational exposure to pollutants with varying contribution across regions, were the main risk factors for COPD in Asia³⁷ which might play a role in the disease prevalence or severity together with the socioeconomic status.¹

Smoking Patterns

Recent studies on smoking patterns among patients with COPD in Singapore showed high rates of continued tobacco use despite a COPD diagnosis. The studies reveal current smoking rates ranging from 40.9% to 50.4%.^27,29 Despite the well-established causal relationship between smoking and COPD, a significant proportion of patients use tobacco following diagnosis. Ministry of Health reports that, Singapore exhibits a comparatively lower national smoking prevalence than that of other Asian countries, with rates declining from 13.9% in 2010 to 10.1% in 2020. This is attributed to the comprehensive tobacco control measures implemented by the Ministry of Health, Singapore.³⁸ This trend emphasizes the effectiveness of public health interventions at the population level, although individual-level cessation remains a challenge in COPD cohorts. The current GOLD guidelines emphasize smoking cessation as a crucial intervention in COPD management, as cessation at any disease stage can reduce progression, alleviate daily symptoms, and decrease exacerbation risk.¹

COPD affects 3–10% of non-smokers, emphasizing the importance of non-smoking risk factors. These include biomass fuel use, occupational exposures, past pulmonary tuberculosis, chronic asthma, childhood respiratory infections, air pollution, and low socioeconomic status. The Singapore Longitudinal Ageing Studies confirm similar prevalence and risk patterns in non-smokers.³⁹ Recent evidence from the 2020 National Health Interview Survey shows that female participants who never smoked had almost twice the COPD prevalence of non-smoking male participants (3.2% vs. 1.7%), with female participants having a 62% higher risk of COPD among non-smokers. This gender disparity persisted across all age groups, suggesting that factors beyond smoking contribute significantly to the COPD risk in female patients.⁴⁰

These outcomes highlight two critical priorities for COPD management strategies in Singapore: strengthening smoking cessation support programs for the large population of current smokers and investigating non-smoking COPD phenotypes that may require alternative preventive, diagnostic, and therapeutic approaches. The urban environment of Singapore contributes additional risk factors including occupational exposure and ambient air pollution.^41,42

Severity

The GOLD guidelines have recently introduced the ABE classification system for COPD, which simplifies the disease categories as follows: A (mild), B (moderate), and E (exacerbator). This system focuses on the symptom burden and exacerbation history to guide treatment decisions (Table 3).¹

Table 3 ABE Classification for the Initial Treatment Consideration as per the GOLD 2026 Guidelines1

The severity distribution of COPD in Singapore, as classified by the GOLD staging criteria, demonstrates a remarkable consistency across multiple observational studies.^3,25–27,29 Figure 2 illustrates moderate disease (GOLD Stage II) as the predominant presentation, accounting for 28.7–49.3% of patients across all studies. Mild disease (GOLD Stage I) represents approximately 21.7–29.0% of cases, whereas severe disease (GOLD Stage III) exhibits some variation between studies (13.5–23.3%). Very severe COPD (GOLD Stage IV) consistently comprises the smallest proportion of patients (0.8–4.0%).^3,25–27,29 The substantial proportion of patients with moderate-to-severe disease suggests opportunities for targeted interventions to prevent progression to more severe stages of disease. Meanwhile, the relatively small but substantial population with very severe disease likely requires intensive healthcare resources and specialized management approaches, such as pulmonary rehabilitation or long-term oxygen therapy. Dupilumab or mepolizumab (not yet approved in Singapore at the time of writing) may be considered as a treatment option for patients with COPD with blood EOS ≥300 cells/µL who continue experiencing frequent exacerbations despite triple therapy.¹ Dupilumab has demonstrated efficacy in reducing exacerbation rates, which is crucial since exacerbations are associated with lung function decline and increased mortality risk.^15,16

Figure 2 GOLD stages of severity in Singapore. Abbreviations: FEV1, forced expiratory volume in 1 second; GOLD, Global Initiative for Chronic Obstructive Lung Disease.

The consistency of these findings across different periods and patient cohorts strengthens their reliability and highlights the need for a comprehensive COPD management strategy that addresses the full spectrum of disease severity, with particular emphasis on early intervention for the large population with moderate-to-severe disease.

Comorbidities

Comorbidities play a crucial role in the clinical presentation, management, and outcomes of patients with COPD in Singapore. As illustrated in Table 4, several studies have documented the prevalence of various comorbid conditions among patients with COPD, revealing a complex landscape of multimorbidity.^3,26–30 Patients with COPD have comorbidities, such as cardiovascular disease, diabetes, hypertension, osteoporosis, lung cancer, and mental health issues, either directly linked with inflammation underlying COPD, associated with treatment (eg, osteoporosis from steroid use), or linked to shared risk factors such as smoking.^43,44

Table 4 Comorbid Conditions Among Patients with COPD in Singapore

Hypertension consistently emerges as the most prevalent comorbidity, affecting 36% to 50.8% of patients across studies. Diabetes mellitus is also prominent, with prevalence rates ranging from 10.3% to 32.6%, highlighting the interplay between metabolic disorders and COPD. Cardiovascular comorbidities are notably common, with heart disease reported in 5% to 41.2% of patients and heart failure in 5.9% to 18%.^3,27–30 Patients with COPD have a 2- to 5-fold increased risk of developing ischemic heart disease, heart failure, arrhythmias, or peripheral vascular disease. The coexistence of COPD and cardiovascular disease complicates the diagnostic process. Soriano et al reported that COPD was underdiagnosed in 60% of patients with cardiovascular disease and in 87% of those with ischemic heart disease.^45,46 The coexistence of asthma and COPD shows considerable variation across studies (6.0–36.6%), possibly reflecting differences in diagnostic criteria or study populations. The concern regarding inappropriate or prolonged use of OCSs in the absence of appropriate disease diagnosis is particularly higher in cases of undiagnosed patients with COPD or those misdiagnosed with asthma.^47,48 Other significant comorbidities include hyperlipidemia/dyslipidemia (23.8–59.5%), chronic kidney disease (7.2–16.4%), and bronchiectasis (7.8–9.3%).^3,27–30 Moreover, 25% of prevalence was recorded in patients with COPD presenting with mild cognitive impairment.⁴⁹

A long-term study revealed that patients treated with OCSs faced substantially increased disease risks compared with those not exposed to OCS: 26% higher for cardiovascular complications, 80% for osteoporosis and fractures, and 44% for type 2 diabetes.⁴⁸ These findings align with research identifying distinct “high-risk” clusters among Chinese patients with COPD in Southeast Asia (Singapore, Malaysia, and Hong Kong), particularly the cardiovascular and ex-tuberculosis clusters, which demonstrate the highest mortality and complex cytokine networks.⁵⁰

The high prevalence of these comorbidities emphasizes the need for a comprehensive, multidisciplinary approach to COPD management in Singapore. Such an approach, beginning with a simple spirometry analysis for diagnosis, involves collaboration among various healthcare professionals, including pulmonologists, cardiologists, endocrinologists, and primary care physicians. This integrated care model ensures a comprehensive assessment and treatment of both respiratory and comorbid conditions, improving patient outcomes, and a simple spirometry analysis to rule out COPD. Clinicians must be vigilant in screening for and managing these concurrent conditions as they can significantly impact COPD symptoms, exacerbation rates, and overall prognosis. Furthermore, the complex interplay between COPD and its comorbidities necessitates tailored treatment strategies that consider potential drug interactions and cumulative treatment burdens.

Disease Burden, Quality of Life, and Economic Costs

COPD significantly impacts the quality of life (QoL) of patients and imposes economic burden on these patients in Singapore. Multidimensional questionnaires are recommended to assess the broader impact of COPD on patients beyond dyspnea.¹

In a single-center observational study, 51% of patients lacked COPD Assessment Test (CAT) scores and 42% had no lung function data; however, the available data suggested that patients were moderately symptomatic (median CAT score: 10), with mild/moderate lung function impairment (GOLD grade I: 26%; GOLD grade II: 49%).²⁹ This pattern of underassessment was further confirmed in a study of 268 patients hospitalized for COPD exacerbations, wherein only 65.7% of patients had recorded lung function tests and 74.6% had documented CAT scores. Among those patients with available data, the median CAT score was 12 (interquartile range [IQR]: 7–17), indicating moderate symptom burden, with 65.5% of patients scoring ≥10, which suggested clinically significant symptoms.²⁷ Lung function tests revealed a median post-bronchodilator forced expiratory volume in 1 s (FEV₁) of 63% predicted, with 44.3% of patients classified as GOLD grade II (moderate airflow limitation). Patients prescribed LAMA+LABA combination therapy demonstrated a significantly worse QoL, with higher CAT scores and worse lung function (median FEV₁ 55% predicted) than those prescribed LAMA monotherapy (72% predicted) or ICS+LABA (68% predicted).^27,29 These findings from single-center studies underscore the critical need for a routine QoL assessment using validated tools to guide appropriate treatment decisions and optimize patient outcomes.

The economic burden of COPD in Singapore represents a significant public health concern. Earlier estimates by Teo et al indicated that COPD cost major public health clusters in Singapore approximately US$ 9.9 million annually between 2005 and 2009, with inpatient hospitalizations being the major cost driver, accounting for 73% of total expenditures. The study revealed that hospitalization costs averaged US$ 7.2 million per year, whereas outpatient care, emergency department (ED) visits, and primary care contributed to 17%, 5%, and 3% of the overall costs, respectively.³² Woo et al later estimated the annual societal cost per capita for COPD in Singapore at US$ 2700, which included both direct medical costs and indirect costs such as productivity losses. The direct healthcare costs were primarily driven by inpatient hospitalizations (68%) followed by ED visits (32%).^32,51

Hospitalization and Mortality Burden

The data on COPD hospitalization rates in Singapore are limited. However, recent data from Alsuwaigh et al provided important insights into healthcare utilization patterns, particularly regarding ED visits and subsequent hospitalizations. The study revealed a distinct pattern: 24.6% of patients required multiple (>2 folds) ED visits leading to hospitalization due to exacerbations, indicating a subset of patients with more severe or poorly controlled disease. Additionally, 31% of patients experienced a single ED visit requiring hospitalization, whereas 44.4% of patients managed their condition without requiring hospitalization.²⁷ These findings are complemented by earlier data from the Asia-Pacific region from Lim et al, who reported that 19% of patients were hospitalized in the previous 12 months due to their condition.³

Yii et al analyzed 2774 COPD admissions in Singapore, reporting a 30-day readmission rate of 27%, which declined from 31% (2017–18) to 21% (2022–23). Key predictors included a higher Charlson Comorbidity Index score (CCI: 2–3 vs. 1, odds ratio [OR]: 1.50; CCI: ≥4 vs. 1, OR: 2.00) and an elevated Hospital Frailty Risk Score (HFRS: ≥5 vs. <5, OR: 1.29). After adjusting for multimorbidity and frailty, the odds of readmission fell by 32% to 35% in 2021–23 compared with those in 2017–18—an improvement masked in unadjusted analyses. These findings underscore the need to account for patient complexity when evaluating COPD care performance.²⁵

The impact of physical frailty on hospitalization and mortality outcomes was particularly noteworthy, as demonstrated in a longitudinal study of 1116 patients over 8.2 years. Prefrailty or frailty was independently associated with a 1.8-fold increase in the mortality risk (adjusted hazard ratio [HR]: 1.83; 95% confidence interval [CI]: 1.24–2.68) compared with that in robust patients with COPD. This risk was further amplified when frailty co-occurred with poor lung function (FEV₁ <80%) or dyspnea, resulting in a 2.4-fold to 3.25-fold increase in mortality risk. Notably, patients in the highest risk category of a combined prognostic index (incorporating physical frailty, FEV₁ <80%, and dyspnea) showed up to an 8.96-fold increase in mortality risk despite adjusting for confounding factors.³⁹ The Integrated Care Pathway (ICP) for COPD, developed by Wu et al,⁵² is a structured, multidisciplinary program ensuring coordinated care across primary, hospital, and home settings. The ICP aims to improve outcomes through evidence-based care while reducing hospitalizations. By year 2, the ICP reduced COPD-related hospitalizations by 27% and bed days by 22%, whereas compliance with the all-or-none care bundle rose from 28% to 54%.⁵² A CGH study evaluated a multidisciplinary telehealth program for 845 high-risk patients with COPD (mean age: 77.9 years). The intervention group showed greater reductions in both COPD-related and all-cause admissions compared to the control group, with 26 fewer COPD-related and 38 fewer all-cause admissions per 100 patients over 12 months.⁵³ Two recent population-based studies highlighted the substantial economic burden of COPD utilizing Singapore’s national health administrative data.^35,54 Juang et al⁵⁴ reported average direct medical costs of SGD 5291 per patient/year among 18866 COPD patients, predominantly driven by hospitalization (70.1%). Only one-third of costs are directly attributable to COPD, while two-thirds stem from comorbidities particularly other respiratory (15%), circulatory (14.9%), and metabolic (7.8%) diseases. Authors³⁵ report the 20-year projection of cost burden in patients with COPD to be $2.4 billion (2024–2043) mainly due to outpatient visit costs (54.8%). Metabolic (17.4%), circulatory (17.0%), and other respiratory diseases (9.8%) are major cost contributors alongside COPD (20.3%), disproportionately affecting elderly patients and adult males.³⁵

A significantly higher all-cause mortality was seen in patents with COPD versus non-COPD individuals (HR, 1.80; 95% CI: 1.40–2.30), which worsened with increasing severity.⁵⁵ In this meta-analysis based on 286,314 patients worldwide, Zhao et al reported that smoking, coexisting respiratory diseases (HR, 3.64; 95% CI: 3.10–4.27), cardiovascular diseases (HR, 1.29; 95% CI: 1.10–1.50) and cancers - especially lung cancer (HR, 2.57; 95% CI: 2.04–3.24) were independent determinants of COPD-related mortality.⁵⁵ The mortality landscape of COPD in Singapore has shown notable historical trends. From 1991 to 1998, COPD mortality decreased remarkably by 43.7%, continuing a steady downward trend observed since the 1970s. This decline was evident across genders, although mortality rates in male patients was approximately four folds higher than those in female patients. Ethnic variations in mortality reduction were significant, with Chinese and Indian patients experiencing substantial decreases of 47.6% and 65.0%, respectively, whereas Malay patients showed a less pronounced reduction of only 12.2%.⁵⁶ During the 1988–99 period, the mean COPD mortality rate was 303.1 per 100,000 population, with the highest burden among Chinese and Malay patients, and the lowest among Indian patients. Notably, although a majority of the ethnic groups showed declining mortality trends, Malay male patients exhibited an 11% increase in mortality during this period. These ethnic variations appear to correlate with smoking prevalence, which was the highest among Malay patients (23.5%), followed by Indian (15.9%) and Chinese (13.6%) patients.⁵⁷ These apparent ethnic variations may be due to multiple confounders, such as smoking behaviour, socioeconomic status, and access to care.

Studies report a 17% 1-year mortality rate after COPD-related hospital discharge. Risk factors included male gender, duration of disease >5 years, and poor lung function (FEV₁ <50% predicted). Mortality estimates are likely underestimated because of underdiagnosis, especially in the elderly, with COPD often recorded as a contributory factor rather than the primary cause of death.³¹

The duration of hospital stays also reflects disease severity and mortality risk of patients with complications spending an average of 7.7 days in hospitals 79% longer than the average of 4.3 days for patients without complications. This extended hospitalization correlates with an increased mortality risk and healthcare burden.⁵² Intervention programs has demonstrated promising effects on reducing COPD mortality in Singapore. Disease management programs, which include disease-related education, optimization of evidence-based medications, support from case managers, self-management principles, and timely treatment for exacerbations, have been associated with lower all-cause mortality than standard care.²⁸ These outcomes highlight the critical role of allied health professionals, such as nurses, pharmacists, and respiratory therapists, in delivering comprehensive COPD care, which is a key component that contributes to improved survival and QoL. These findings highlight the complex nature of COPD mortality in Singapore, influenced by smoking prevalence, healthcare interventions, and diagnostic challenges.

Evolution of COPD Management in Singapore: Real-World Evidence and Treatment Patterns

Diagnostic Tools

Spirometry is essential to ensure accurate diagnosis and appropriate management, and serves as the gold standard for COPD diagnosis.^1,58 The international GOLD standard for COPD recommends the use of spirometry as a benchmark for the accurate and repetitive measurement of lung function.¹ However, access to spirometry is often limited in general practice. In Singapore, most general practice clinics do not offer the spirometry services necessary for early diagnosis and staging of COPD to facilitate appropriate disease care.⁵² However, Singapore polyclinics are now progressively establishing spirometry services, which should be further strengthened.

Current Treatment Landscape and Implementation of Guidelines

COPD management in Singapore is hindered by significant challenges, particularly regarding the real-world implementation of treatment guidelines and initial bronchodilator therapy decisions.²⁹ Real-world evidence from CGH has provided valuable insights into treatment patterns. Sim et al revealed that patients initiated on LAMA+LABA typically present with more severe COPD than those prescribed LAMA monotherapy, although similar rates of clinical worsening were observed in both groups, thereby highlighting the critical importance of early disease identification and timely treatment optimization to prevent disease progression.²⁹ A retrospective, real-world, single center study from CGH reported the treatment regimens in various group-based trajectories numbered C1 to C4 based on moderate-to-severe COPD exacerbations. It was seen that “no treatment” was the predominant regimen at baseline in patients in the C1 trajectory, which declined over 3 years and there was an increase in proportion of patients receiving LABA+LAMA. Patients on C2 received triple therapy predominantly but LABA+LAMA was also prescribed and the patients in C3 and C4 trajectories received triple therapy for the entire follow-up period.²⁶ Another retrospective analysis at CGH (October 2018 to April 2020) identified a significant treatment gap, with 84% of patients qualifying for treatment escalation under both GOLD 2019 and 2023 guidelines.²⁷ This finding is particularly relevant given the evolving GOLD recommendations, which now incorporate the blood eosinophil count as a key factor in guiding treatment adjustments for high-risk patients, showing a marked shift from previous approaches that did not rely on this biomarker.²⁷

Moreover, Keeratichananont et al highlighted the emerging role of fractional exhaled nitric oxide (FeNO) testing in COPD management.⁵⁹ The strong correlation between FeNO levels and blood eosinophil counts suggests its potential as a non-invasive biomarker for eosinophilic inflammation. High FeNO levels (≥25 ppb) were linked to poorer outcomes, including increased exacerbations, hospitalizations, and mortality, indicating its value as a prognostic tool. Although larger studies are needed, FeNO testing could play a significant role in COPD management, potentially guiding decisions on the use of ICSs and overall treatment strategies.⁵⁹

The translation of guidelines into clinical practice remains challenging, as evidenced by an observational study across Southeast Asia and Australasia, including three Singapore sites, which found that only 80% of ED-diagnosed patients with COPD received bronchodilator treatment.^29,60 Safety considerations further complicate treatment decisions, particularly regarding the use of ICSs in combination with long-acting bronchodilators, which has been associated with up to a 39% increased relative risk of pneumonia.²⁷

Emerging Therapeutic Approaches and Future Directions

While current management strategies in Singapore focus on optimizing bronchodilator and ICS therapies, the landscape of COPD treatment is poised for significant evolution with the advent of biologic therapies. Table 5 presents several active clinical trials investigating the effects of biologics in patients with COPD, targeting various inflammatory pathways implicated in disease progression.^61–71 These include agents targeting type 2 inflammation (such as mepolizumab and benralizumab targeting IL-5, and dupilumab targeting IL-4 and IL-13) and those targeting alarmins (including itepekimab and tozorakimab targeting IL-33, astegolimab targeting ST-2, and tezepelumab targeting thymic stromal lymphopoietin [TSLP]).¹⁷

Table 5 Therapeutic Targets for the Biological Treatment of COPD61–71

The recent approval of some biologics and ongoing trials for others may herald a new era of precision medicine in COPD management, offering targeted treatment options for specific patient subgroups. The US FDA, the European Medicines Agency (EMA), and the Health Sciences Authority, Singapore have recently approved dupilumab and mepolizumab (US FDA, EMA) as an add-on maintenance treatment for uncontrolled COPD characterized by elevated blood eosinophil counts in patients who are prescribed a stable combination of an ICS, a LABA, and a LAMA, or a combination of a LABA and a LAMA in case an ICS is not appropriate.^14,15 This landmark development introduces biologics targeting the type 2 inflammatory pathway, which is involved in approximately 20–40% of patients with COPD.⁷² The GOLD 2026 guidelines suggest that patients experiencing persistent exacerbations despite triple therapy (LABA+LAMA+ICS) with a blood eosinophil count of ≥300 cells/μL may be suitable candidates for dupilumab co-treatment.¹ Although biologics for COPD have received regulatory approval, their real-world implementation in Singapore is likely to be constrained by substantial costs, uncertainty regarding cost-effectiveness, requirement for biomarker identification and careful patient selection, and insufficient integration of biologic treatment pathways within primary care settings. Collectively, these challenges likely limit the early adoption to specialized centers and carefully selected patients, emphasizing the need for locally generated effectiveness and health economic evidence.

The evolution of COPD management in Singapore necessitates a comprehensive approach to address current gaps in patient care. Establishing a nationwide integrated care program, supported by a multidisciplinary approach involving pulmonologists, primary care providers, and allied health professionals, is crucial for delivering coordinated and patient-centric care. Access to spirometry for early diagnosis represents a key potential future direction that should be implemented countrywide to facilitate timely intervention. Ongoing real-world studies utilizing routine clinical practice data, coupled with the development of robust guidelines for the selection of novel therapy, particularly biologics, will be essential. These strategic efforts will enable more personalized and effective COPD management in Singapore, while ensuring the optimal use of healthcare resources, ultimately improving patient outcomes in real-world clinical settings.

Adherence to Treatment in Singaporean Patients with COPD

Treatment adherence remains a significant challenge in COPD management, with multiple factors influencing patients’ ability to follow prescribed therapeutic regimens. Adherence is a key determinant of treatment outcomes in COPD management as non-adherence to COPD medication has been associated with poor symptom control, an increased risk of exacerbations, increased healthcare utilization and costs, decreased health-related QoL, and higher mortality rates.^1,73 COPD non-adherence occurs in two forms: intentional (due to medication beliefs and concerns regarding side effects) and unintentional (due to regimen complexity and technique issues). Both types of non-adherence led to worse clinical outcomes, including increased exacerbations and disease progression.^74–76

Recent research by Sim et al provides important insights into medication adherence patterns in Singapore.²⁹ The study demonstrated a relatively high median medication dispensation rate of 0.86 (IQR: 0.56–1.00), where the dispensation rate was defined as the ratio of inhalers dispensed to inhalers prescribed during the follow-up period.²⁹ Notably, adherence as assessed by the medication dispensation rate was high across different groups, suggesting that differences in disease severity were not related to differing rates of adherence.²⁹

Additionally, the complexity of inhaler device usage poses a challenge to COPD treatment adherence. Up to 60% of patients commit critical inhaler technique errors, potentially reducing medication effectiveness and disease control, even with regular medication use.⁷⁷ To address these challenges, successful adherence interventions must be multifaceted, incorporating patient education, simplified treatment regimens, regular technique assessment, and consideration of cultural factors.

Limitations

This narrative review provides valuable insights into the COPD prevalence, severity and management in Singapore; however, we should consider the limitations while interpreting these findings. The paucity of long-term real-world data, current uncertainties regarding patient selection and health-system considerations play a substantial role in overall COPD outcomes and management. The evidence base for the COPD landscape in Singapore is further constrained, as the current literature is predominantly derived from the studies conducted at Changi General Hospital, with very few population-based studies and few reports from the Health Ministry. Most of the interpretations in this review are consequently drawn from this limited body of evidence. While factors impacting hospitalization and risk factors for mortality appear consistent with findings reported in the international literature, lack of cause-specific mortality data for patients with COPD in Singapore remains a notable evidence gap that warrants attention in future research.

Conclusions

COPD in Singapore presents unique challenges despite reductions in age-standardized prevalence and mortality rates. This study highlights critical gaps in current practice: underutilization of diagnostic tools resulting in a substantial proportion of patients remaining inadequately assessed, substantial treatment gaps, and the need for culturally tailored approaches across diverse ethnic groups in Singapore. To address these challenges effectively, healthcare systems should enhance accessibility of spirometry in primary care settings, develop integrated care pathways, and establish clear protocols for the implementation of biologic therapy.

In particular, the patient population for dual/triple therapy typically includes those with moderate-to-severe COPD. Despite optimized inhaler triple therapy, a subset of patients continues to experience exacerbations.^78,79 Dupilumab, recently approved in Singapore (2025) as the first biologic for COPD in patients with moderate-to-severe elevated eosinophils, may offer new hope to improve patient outcomes. Biologics specifically target type 2 inflammation pathways in COPD, offering precision medicine for patients with identifiable inflammatory endotypes.^79,80 These focused efforts will be crucial in addressing the projected increase in COPD burden associated with population aging in Singapore, ultimately improving outcomes for this heterogeneous patient population.