Combined bronchodilator therapy in the management of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a leading cause of death and disability. There is now a better understanding of the pathophysiology of COPD and of the effectiveness of various treatment strategies in controlling symptoms and progression of disease. Although cessation of smoking is of primary importance, the growing realization in recent years that airflow limitation in COPD can be significantly relieved with the use of bronchodilators has changed the clinical approach to treating this disease. As a result, inhaled bronchodilators have become the therapy of choice in new pharmacological treatment algorithms for COPD. Additionally, the improvement in airflow limitation seen with bronchodilators, if maintained by patient compliance, can result in an improved level of lung function. Inhaled beta 2-adrenergic agonists are effective bronchodilators with a relatively rapid onset of action. They may also have additional value in that they can increase mucociliary clearance in the airways. Inhaled anticholinergic bronchodilators, such as ipratropium bromide, have been shown to be more effective bronchodilators than beta 2-agonists in COPD; they are associated with a low incidence of side-effects and may decrease the number of pulmonary exacerbations. The use of the combination of these two classes of inhaled bronchodilators provides superior bronchodilation than treatment with either of the individual components without added side-effects or loss of the positive effects of ipratropium bromide including reduced exacerbation frequency and lack of tachyphylaxis. The use of combination therapy also improves cost-effectiveness and patient compliance. Combination therapy should be considered as an important component of a treatment algorithm of COPD.