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PULMONARY

Long-Acting Bronchodilator Therapy for the Treatment of Chronic Obstructive Pulmonary Disease

Clinical Instructor, Postgraduate Year 2 Internal Medicine Resident, St. Louis College of Pharmacy, St. Louis, MO

Suzanne G Bollmeier, PharmD BCPS AE-C

Associate Professor, Pharmacy Practice, St. Louis College of Pharmacy

Patrick M Finnegan, PharmD BCP

Assistant Professor of Pharmacy Practice, St. Louis College of Pharmacy

Reprints: Dr. Finnegan, St. Louis College of Pharmacy, 4588 Parkview Pl., St. Louis, MO 63110, fax 314/446-4500, pfinnegan{at}stlcop.edu

OBJECTIVE: To review clinical data on the use of long-acting bronchodilator agents as monotherapy and in combination for the treatment of moderate-to-severe chronic obstructive pulmonary disease (COPD).

DATA SOURCES: A literature search was performed via MEDLINE (1966-April 2008). In addition, references from publications identified were reviewed. These searches were limited to human data published in the English language. Searches used the following terms: COPD, long-acting β₂-agonists, long-acting anticholinergics, combination therapy, pharmacoeconomics, safety, tiotropium, salmeterol, and formoterol.

STUDY SELECTION AND DATA EXTRACTION: Relevant information on the pharmacology, safety, efficacy, pharmacoeconomics, adherence, and available agents used in the treatment of COPD was selected. Randomized clinical trials and retrospective reviews were included.

DATA SYNTHESIS: The Global Initiative for Chronic Obstructive Lung Disease guidelines provide general management recommendations to guide providers regarding treatment choices for COPD; however, they lack clarity regarding which long-acting bronchodilator to use and when combining agents becomes appropriate. Prospective trials evaluating short-acting anticholinergics and long-acting β₂-agonists have utilized spirometric endpoints that relate most to short-term symptomatic relief. Tiotropium trials have focused more on patient-oriented outcomes, with data being reported for one year. Tiotropium significantly lowers exacerbation rates and improves health resource usage as well as health-related quality of life. Tiotropium also provides superior bronchodilation and improvement in dyspnea at all time points, although onset of bronchodilation is slower than with long-acting β₂-agonists. Combining these agents has been shown to decrease daytime rescue inhaler use, improve morning and evening peak expiratory flow rates, and improve bronchodilator efficacy compared with monotherapy. Pharmacoeconomic data lend support to the recommendation of tiotropium as a first-line long-acting agent.

CONCLUSIONS: Tiotropium appears to be the best option as a first-line drug for patients with moderate-to-severe COPD because of its ability to sustain bronchodilator effect, improve quality of life, reduce COPD exacerbations, and reduce health resource usage. Patients who remain symptomatic may benefit from the addition of a long-acting β₂-agonist to tiotropium monotherapy.

Key Words: combination therapy, COPD, formoterol, long-acting anticholinergics, long-acting β₂-agonists, pharmacoeconomics, safety, salmeterol, tiotropium

Published Online, October 28, 2008. www.theannals.com, DOI 10.1345/aph.1L250

THIS ARTICLE IS APPROVED FOR CONTINUING EDUCATION CREDIT
ACPE UNIVERSAL PROGRAM NUMBER: 407-000-08-024-H01-P