Source: Eur Respir Rev 2005; 14: 23-31
Disease area: Airway diseases

Abstract

Since airflow obstruction in chronic obstructive pulmonary disease (COPD) is to some extent reversible, bronchodilators play an important role in the maintenance treatment of COPD the more they reduce hyperinflation and, as a result, improve dyspnoea and exercise capacity. Since parasympathetic activity is the dominant reversible component of airflow obstruction in COPD, inhaled short-acting anticholinergic agents (SAAC), in particular ipratropium, became an efficient and safe first-line treatment, especially when combined with a short-acting beta2-adrenergic receptor agonist. Even better results were obtained when combining the SAAC ipratropium to a long-acting beta2-adrenergic receptor agonist (LABA), once they became available. Recently, tiotropium bromide, the first of a new class of selective and long-acting anticholinergic agents was introduced for once-daily maintenance treatment of COPD patients. Several large long-term randomised clinical trials comparing tiotropium to placebo as well as to the SAAC ipratropium and the LABA salmeterol, have confirmed the long-acting and superior bronchodilator effect of tiotropium without any evidence of drug tolerance developing. These studies also have clearly demonstrated that tiotropium positively affects several other important health outcomes, such as dyspnoea sensation, exercise capacity, utilisation of rescue bronchodilators, health-related quality of life, COPD exacerbations and hospitalisations because of exacerbations. The improvement in these real-life outcomes appears related to the reduction in both static and dynamic hyperinflation. In all these studies, tiotropium was well tolerated and safe; the only relevant side-effect encountered being dry mouth, usually mild and often transitory. Finally, it has been shown that the combination of tiotropium with a LABA affords superior bronchodilatation than both agents alone, indicating that both classes of long-acting bronchodilators should be regarded as complements rather than opponents. In conclusion, a sufficiently large and convincing database now exists to propose the once-daily long-acting anticholinergic tiotropium as first-line maintenance treatment for all chronic obstructive pulmonary disease patients in global initiative for chronic obstructive lung disease (GOLD)-class II and above, with a step-up to its combination with a long-acting beta2-adrenergic receptor agonist in case of suboptimal clinical effect.

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Citations should be made in the following way:
Vincken W.. Bronchodilator treatment of stable COPD: long-acting anticholinergics. Eur Respir Rev 2005; 14: 23-31

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