[Fixed Combination of a Long-Acting beta(2)-Agonist and an Inhaled Steroid. A Therapeutic Option for COPD?]

The introduction of long-acting bronchodilators (beta(2)-agonists and anticholinergics) has essentially changed the therapy of chronic obstructive pulmonary disease (COPD) in the last years. Furthermore, the understanding of the pathophysiology of the disease has improved, leading to a reevaluation of essential therapeutic principles. Especially, the significance of inhaled steroids in elder and sicker patients is now being acknowledged.

For a long time, the use of the fixed combination of an inhaled steroid and a long-acting beta(2)-agonist seemed to be reserved for the therapy of bronchial asthma, as there was clinical as well as pharmacologic evidence of a synergism of the therapy components, i. e., increase in beta(2)-receptor density and responsiveness by the steroid and activation of the glucocorticoid receptor by the beta(2)-agonist. However, first studies in COPD showed significant, clinically relevant improvement of the classic outcome parameter pulmonary function as well as of symptoms, especially dyspnea, quality of life and incidence of severe exacerbations, exceeding solely additive effects of the monosubstances.

According to clinical data, the supposed synergism is very likely, even though pharmacodynamic evidence is not yet available. However, the beneficial effect of combination therapy could be demonstrated for older patients with more severe disease (FEV(1) < 50%, history of frequent exacerbations) only. Further studies will be needed to clarify, if other patient groups will benefit from this therapy option and which dosage is to be regarded as optimal.