Anticholinergic drugs for COPD

Anticholinergic drugs for COPD

Should anticholinergic drugs be first-line agents for preventing exacerbations in patients with chronic obstructive pulmonary disease (COPD)? The answer may be yes, according to a new study in the New England Journal of Medicine. Researchers from Europe compared the anticholinergic drug tiotropium to the beta-agonist salmeterol in more than 7000 patients with moderate-to-very-severe COPD. The study was a randomized, double-blind, double-dummy, parallel-group trial in which tiotropium once a day was compared to salmeterol twice a day. The endpoint was the incidence of moderate or severe exacerbations. Over the 1-year study, tiotropium increased the time to first exacerbation compared to salmeterol (187 days vs 145 days, 17% risk reduction, hazard ratio [HR] 0.83; 95% confidence interval [CI], 0.77 to 0.90; P < 0.001). Tiotropium also increased the time to first severe exacerbation (P < 0.001), reduced the annual number of moderate or severe exacerbations (0.64 vs 0.72; P = 0.002), and reduced the annual number of severe exacerbations (0.09 vs 0.13; P < 0.001). Adverse events were similar in both groups. There were 64 deaths in the tiotropium group (1.7%) and 78 in the salmeterol group (2.1%). The authors conclude that in patients with moderate-to-very-severe COPD, tiotropium is more effective than salmeterol in preventing exacerbations (N Engl J Med 2011;364:1093-1103). This is the first head-to-head study to show benefit for anticholinergics but it must be pointed out that cardiac patients were excluded from the study, and the annual exacerbation rates were lower than has been seen in other trials. The concomitant use of inhaled corticosteroids was evaluated and did not make a difference in the outcomes. The study was sponsored by Boehringer Ingelheim, the manufacturer of tiotropium (Spiriva).