Which LONG-acting bronchodilator to use first-line for COPD
As a clinical pharmacist, you will hear debate over which long-acting bronchodilator to use first-line for COPD. Guidelines suggest either tiotropium (Spiriva) or a long-acting beta-agonist (salmeterol, formoterol) for persistent symptoms. Both types of bronchodilators improve COPD symptoms, but tiotropium seems to work better to prevent exacerbations.
One more exacerbation can be prevented for every 25 patients treated for one year with tiotropium instead of salmeterol. But there's no proof that any of them reduce mortality. Tiotropium is given once daily, compared to twice daily with salmeterol or formoterol. And consider the cost factor.
Lean toward tiotropium first if cost isn't a problem, especially for patients with heart disease. Beta-agonists might worsen heart failure, or reduce the efficacy of beta-blockers. Be careful about using tiotropium in men with benign prostatic hyperplasia, due to possible urinary retention. Recommend both tiotropium and a long-acting beta-agonist if needed. Suggest saving inhaled steroids or steroid/beta-agonist combos (Seretide, etc) for more severe COPD. Explain that inhaled steroids are linked to a higher risk of pneumonia and fractures.
References
- Vogelmeier C, Hederer B, Glaab T, et al. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. N Engl J Med. 2011;364(12):1093-1103.
- Global Initiative for Chronic Obstructive Lung Disease - GOLD (2020). https://goldcopd.org/gold-reports.
- Hawkins NM, Petrie MC, et al. Heart failure and chronic obstructive pulmonary disease the quandary of Beta-blockers and Beta-agonists. J Am Coll Cardiol. 2011 May 24;57(21):2127-38.
