Long-acting anticholinergic use in chronic obstructive pulmonary disease: efficacy and safety

This article reviews findings from recently published randomized controlled trials and systematic reviews to provide an up-to-date assessment of the efficacy and safety of tiotropium, the only currently available long-acting muscarinic antagonist, when used alone or in conjunction with other respiratory medications in the treatment of chronic obstructive pulmonary disease (COPD).

Results of recent clinical trials support findings from earlier trials in patients with moderate to very severe COPD demonstrating significant benefits of tiotropium compared to placebo, including sustained increases in lung function, reductions in exacerbations and risk of exacerbation-related hospitalizations, and improvement in health status. These benefits were particularly noted in the 4-year UPLIFT study that included 5993 COPD patients, including a large percentage with moderate severity. Whereas the cardiovascular safety of tiotropium has been questioned, results of the UPLIFT trial and a recent pooled analysis of data from 30 trials of tiotropium demonstrated that tiotropium is associated with reductions in the risk of all-cause mortality, cardiovascular mortality and cardiovascular events.

Recent findings confirm the benefits of tiotropium in COPD management and provide reassurance regarding its safety. Moreover, the recent UPLIFT trial provides supportive evidence for the efficacy of tiotropium in COPD patients already receiving treatment with long-acting inhaled beta-agonists and inhaled corticosteroids, suggesting advantages of 'triple' therapy in advanced disease. Further, well designed, adequately powered studies should explore the potential advantages and disadvantages of various combinations of currently available long-acting respiratory medications in COPD, particularly in different clinical phenotypes of this heterogeneous disease.