Long-acting maintenance pharmacotherapy in chronic obstructive pulmonary disease

Abstract

Exacerbations, which often lead to emergency department visits and hospitalizations, are the main drivers of morbidity and utilization of health care resources among patients with chronic obstructive pulmonary disease (COPD). Appropriate choice of an effective, long-term pharmacotherapy for reducing exacerbations is key to COPD management. In this review, we summarize the available long-acting, maintenance pharmacotherapeutic options for patients with moderate or severe COPD and discuss practical considerations in the management of these patients. Bronchodilators are the cornerstone of pharmacological treatment for COPD, and long-acting muscarinic antagonists (LAMAs) are recommended as initial treatment for most patients with COPD. Dual bronchodilation with a LAMA and long-acting β₂-agonist (LABA), with their synergistic bronchodilatory actions, is the mainstay of long-term COPD maintenance pharmacotherapy for patients with high symptom burden, persistent symptoms, or exacerbations. Evidence hints that the effects of different LAMA + LABA combinations may not always be similar, suggesting the presence of an efficacy gradient. However, large-scale clinical trials directly comparing different LAMA + LABA combinations are needed to support or refute this observation. Use of an inhaled corticosteroid in addition to LABA or LAMA + LABA as the initial or follow-up pharmacological treatment is now guided by eosinophil count thresholds. In addition to various medication options, different inhalation devices are available to deliver the medications. When making treatment decisions, medication class, inhalation device, patient and disease characteristics, and patient goals and preferences should be considered.