The Role of Long-Acting Bronchodilators in the Management of Stable COPD*

Tashkin, Donald P. MD, FCCP
Cooper, Christopher B. MD, FCCP

*From the Division of Pulmonary and Critical Care Medicine and the UCLA Pulmonary Function and Exercise Physiology Laboratory, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Dr. Tashkin has received consulting fees from Boehringer Ingelheim, and Dr. Cooper has received consulting fees from Boehringer Ingelheim and is affiliated with the Boehringer Ingelheim Speakers' Bureau.

Manuscript received October 28, 2002; revision accepted April 14, 2003.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]).

Correspondence to: Donald P. Tashkin, MD, FCCP, Division of Pulmonary and Critical Care Medicine, UCLA School of Medicine, PO Box 951690, 10833 Le Conte Ave, Los Angeles, CA 90095-1690; e-mail: [email protected]

Chest 125(1):p 249-259, January 2004.

Bronchodilators form the foundation of symptomatic treatment of COPD. Several long-acting bronchodilators are now available for use in COPD, but publications of large-scale studies of their efficacy have, for the most part, postdated the publication of major clinical guidelines. This article provides a critical review of large (≥ 50 patients), double-blind, clinical trials of three long-acting bronchodilators in COPD (the once-daily anticholinergic tiotropium, and the twice-daily β₂-agonists formoterol and salmeterol) within the context of the objectives of treatment defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Fourteen published studies were identified, of which 12 studies were published since the release of the GOLD guidelines. All three long-acting bronchodilators were found to effectively improve lung function; however, they differed in their effects on outcomes other than bronchodilation, with salmeterol demonstrating inconsistent efficacy compared with placebo in preventing exacerbations and improving health status, and only tiotropium demonstrating consistent superiority to the short-acting bronchodilator ipratropium. Based on this review, a treatment algorithm for the introduction of long-acting bronchodilators to patients with COPD is proposed, which includes the use of long-acting bronchodilators early in the treatment algorithm.