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Combination Therapy Works Best in COPD

combination therapy copdUsing the best scientific information available, the guidelines for COPD treatment were updated in January, 2015, by the Global Initiative for Obstructive Lung Disease (GOLD).  Although much has changed since the first GOLD report in 2001, one factor has stood the test of time: improving symptoms, reducing the frequency and severity of COPD exacerbations, and improving health status and tolerance to exercise remain the primary goals of COPD treatment.[1]


Bronchodilators are medications that reduce inflammation and relax the breathing tubes making it easier to breathe. Bronchodilators are divided into 3 classes, or groups of drugs:

  1. Beta agonists can be short-acting (albuterol, metoproterenol) lasting up to 4 hours, or long-acting (formoterol, salmeterol), lasting 12 hours or more, respectively. Although they can be taken by mouth, the inhaled method is preferred for people with COPD.
  2. Anticholinergics (Spiriva, Combivent, Atrovent) can only be delivered through an inhaler. They provide long-lasting relief for COPD symptoms with minimal side effects.
  3. Methylxanthines are less commonly used in the treatment of COPD and include theophylline (given by mouth) or aminophylline (given through an IV).

Monotherapy vs. Combo Therapy: And the Winner Is

According to GOLD guidelines, using a short-acting, or long-acting, beta agonist or anticholinergic inhaler is the first line of treatment for people with COPD. But many doctors feel that combination therapy (two or more medications) is more effective, even as an initial treatment option. Does the research agree?

A current study published in The Journal of the American Medical Association suggests that a single bronchodilator (monotherapy) does little to improve symptoms in some patients with moderate to severe COPD. Many times, adding a second medication from another class of drugs is highly beneficial.[2]

The study involved 12,000 people with COPD between 2003 and 2011. Of these, 8,712 patients were new users of combination therapy and 3,160 were new users of single drug therapy involving a long-acting beta agonist.

During the study, 37.3% of patients who received single drug therapy died, compared to 36.4% of patients using combination therapy. Similar results were seen with hospitalizations associated with COPD – approximately 30.1% of patients treated with monotherapy were hospitalized, compared to 27.8% of patients treated with combination therapy. Researchers concluded that overall, the use of combo therapy reduced the risk of death by 3.7%, compared to using beta agonists, alone.

Greater Benefits for COPD Patients with Asthma

People with COPD who were also diagnosed with asthma experienced an even greater difference between the two types of drug therapy. Compared to those taking a single drug, people who used combo therapy experienced a 6.5% reduction in death and hospitalizations.

Doctors Already “Doing the Right Thing”

Researchers were quick to point out that most doctors who specialize in the lungs are already “doing the right thing” by prescribing a combination of medications as opposed to just one. In fact, during the study period, researchers discovered that doctors had started 34,289 new patients on combo therapy, compared to starting 3,258 new patients on beta agonists, alone.

Doctor Darcy Marciniuk, one of the authors of the study, summed it up by saying “About 10 times more people were started on combination therapy than were started on the single therapy. That speaks for itself.”[3]


[1] “Global Strategy for the Diagnosis, Management, and Prevention of COPD.” Global Initiative for Obstructive Lung Disease. Updated January, 2015.

[2] Ridolo E, et. al. “Combination therapy with indacaterol and glycopyrronium bromide in the management of COPD: an update on the evidence for efficacy and safety.” Ther Adv Respir Dis. 2015 Feb 17. pii: 1753465815572065. [Epub ahead of print].

[3] Gershon AS, Campitelli MA, Croxford R, et al. Combination Long-Acting β-Agonists and Inhaled Corticosteroids Compared With Long-Acting β-Agonists Alone in Older Adults With Chronic Obstructive Pulmonary Disease. JAMA. 2014;312(11):1114-1121. doi:10.1001/jama.2014.11432.


by Deborah Leader RN, BSN, PHN


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