Evolving therapies in chronic obstructive pulmonary disease

• An estimated three million people die of chronic obstructive pulmonary disease (COPD) every year, and the prevalence of COPD is increasing. By 2020, COPD is expected to become the third-leading cause of death worldwide. • The burden of illness associated with COPD is high. Both the disease itself and common comorbidities, such as cardiovascular disease, asthma, diabetes and mental health problems, have a negative impact on the health status of patients with all disease severities. • COPD treatment costs in primary care are substantial and due mainly to costs of medication; hospitalization represents the major cost driver in secondary and tertiary care. • Early diagnosis and treatment of COPD may lessen the burden of disease. • Together with smoking cessation and other nonpharmacologic approaches, optimal pharmacological treatment and correct inhaler use are important for successful therapy outcomes. • According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy, patients should be assessed and treated according to their degree of COPD symptoms and risk of exacerbations (based on the degree of airflow limitation and history of exacerbations). In the GOLD 2014 management strategy for stable COPD, bronchodilators are the cornerstone of pharmacologic disease management. • GOLD firstand alternative-choice treatment recommendations for patients with persistently symptomatic disease are: long-acting β2-adrenergic agonists (LABAs), long-acting muscarinic antagonists (LAMAs) or combination therapy with a LABA/LAMA. • Several LABA and LAMA monotherapies have well-established safety and efficacy profiles. Combining these different agents may improve clinical outcomes and decrease the risk of side effects, compared with increasing the dose of a single bronchodilator. • Use of phosphodiesterase-4 inhibitors with long-acting bronchodilators and/or inhaled corticosteroids (ICS), or ICS/LABA combination therapy is effective in appropriate patients with severe or very severe disease at high risk of exacerbations. Triple therapy with ICS/LABA/LAMA combinations appears promising, but more data are needed to confirm the long-term risk–benefit profile of this approach. • Other emerging COPD therapies include single-molecule muscarinic antagonist/β2-agonists, TNF-α antagonists, N-acetylcysteine and its derivatives, CCR1 chemokine receptor antagonists, p38 MAP kinase inhibitors, M3-selective muscarinic antagonists and prophylactic antibiotics. However, the roles of these agents in the treatment of COPD and their potential interaction with existing drugs have yet to be determined. Evolving therapies in chronic obstructive pulmonary disease