Purpose of review: This article reviews findings from recently published randomized controlled clinical trials to address the question whether a long-acting inhaled bronchodilator should be the initial choice for maintenance therapy in patients with stable, symptomatic chronic obstructive pulmonary disease (COPD).
Recent findings: Results of recent clinical trials suggest that a long-acting inhaled bronchodilator, either once-daily tiotropium or twice-daily salmeterol or formoterol, has advantages over a regularly-scheduled short-acting anticholinergic inhaled bronchodilator (ipratropium) as initial maintenance therapy in patients with at least moderate, stable, symptomatic COPD (forced expired volume in 1 second </= 60-70% predicted; mean, approximately 37-45% predicted). For tiotropium, these advantages encompass several important outcomes, including lung function, rescue inhaler use, dyspnea, frequency of exacerbations, and hospitalization for COPD, in addition to greater convenience and therefore potentially better adherence to prescribed therapy, whereas side effects are similar except for a greater incidence of dry mouth.
Summary: Current evidence supports the recommendation of the Global Initiative for Chronic Obstructive Lung Disease guidelines of at least one of the two classes of long-acting inhaled bronchodilators as initial maintenance therapy for symptomatic COPD. In patients who do not respond satisfactorily to tiotropium or a long-acting inhaled beta-agonist as the initially prescribed single maintenance agent, the Global Initiative for Chronic Obstructive Lung Disease guidelines recommend the addition of the alternate class of long-acting inhaled bronchodilator as the next step. Further clinical trials are required to investigate whether this recommendation is preferable to that of adding an inhaled corticosteroid, which has been shown to have additive benefits to those of a long-acting beta-agonist with respect to bronchodilation and, variably, dyspnea, rescue bronchodilator use, and quality of life. The choice of agents will depend ultimately on how well the patient responds to a trial of the drug in terms of both efficacy and side effects, and patient preference and cost.