Chronic obstructive pulmonary disease megatrials: taking the results into office practice

Primary care specialists provide first-line care of chronic obstructive pulmonary disease (COPD), characterized by progressive, partially reversible airflow limitation induced mainly by smoking. Spirometry and questionnaires are important for COPD diagnosis, staging and prognosis. Smoking cessation, immunizations, pulmonary rehabilitation and self-management action plans comprise nonpharmacologic COPD management. The Understanding Potential Long-term Impacts on Function with Tiotropium (UPLIFT®) and Towards a Revolution in COPD Health (TORCH) megatrials provide evidence for maintenance pharmacotherapy to reduce exacerbations and improve patient symptoms and health-related quality of life. Although the primary outcomes--lung function decline (UPLIFT®) and mortality (TORCH)--were negative, long-acting bronchodilators in both trials reduced exacerbation rates and improved health status. Tiotropium added to usual care (in UPLIFT®) and salmeterol/fluticasone therapy (in TORCH) improved key patient-centered outcomes with no significant mortality risk or excess in serious cardiac adverse events associated with the study drugs. These results provide strong evidence of efficacy and acceptable safety profiles of maintenance pharmacotherapies in patient-centered outcomes and support combination drug regimens in patients with moderate to very severe COPD.