Which bronchodilator in COPD?

Which bronchodilator in COPD? There have been few developments in the pharmacotherapy of chronic obstructive pulmonary disease (COPD) that have been so eagerly awaited as that of a long acting anticholinergic compound. For the fi rst time there was a treatment available which was designed with COPD specifi cally in mind. This was not an asthma treatment that had been tried in COPD with more hope than expectation. Tiotropium has now been available in Europe for 5 years and in the US for 3. Has this drug lived up to the expectations with which it was greeted? In this edition of the International Journal of COPD we publish two papers which review the data for the effi cacy of Tiotropium and compare its effects with long acting beta-agonists. The analysis of Rice and colleagues (2007) clearly demonstrates that Tiotropium is an effective bronchodilator in COPD patients. Peak and trough forced expiratory volume in one second (FEV 1) measurements were signifi cantly increased and these changes were sustained throughout the study periods (up to 1 year). Exacerbations of COPD are of great importance to patients, medical staff and medical funding bodies. The fi nding of a reduction in exacerbation rate and hospital admissions is thus of signifi cance. Hodder and colleagues (2007) compare in a post-hoc analysis the effi cacy of tiotro-pium and salmeterol in patients who may or may not be taking inhaled corticosteroids in two studies over a six month period. The fi ndings do not help us understand the role of inhaled steroids in COPD but do demonstrate that both salmeterol and tiotropium are effective notwithstanding the steroid status of the subjects. The patients taking steroids were found to have worse lung function and breathlessness at enrolment. The reduced responses to therapy, particularly the exacerbation rate, may refl ect this. However it was clear that a physician's decision to place a patient on inhaled steroids is based on more than a slightly worse FEV 1 or slightly more breathlessness. There is still a need in such studies to demonstrate clinically meaningful benefi t. Lung function changes are straightforward to measure but do they translate into improvements in quality of life and exercise tolerance? The data presented thus far is relatively weak in this area. Moreover there is a question or the generalisability of the data presented. For reasonable reasons patients with signifi cant co morbidities are excluded (especially …