Recommendations from others
The GOLD (Global Strategy for the Diagnosis, Management, and Prevention of COPD) Report states that the choice between β2-agonist, anti-cholinergics, or combination therapy depends on the availability and the response of a given patient in terms of symptom relief and side effects. The 2003 GOLD Workshop Report update further recommends the use of regular treatment with long-acting bronchodilators, including tiotropium, rather than short-acting bronchodilators for moderate-to-severe COPD.6
A separate report for the Joint Expert Panel on Chronic Obstructive Pulmonary Disease of the American College of Chest Physicians and the American College of Physicians—American Society of Internal Medicine states that both are beneficial for management of acute exacerbations, but that anticholinergics should be considered first because they are associated with fewer and more benign side effects.7
CLINICAL COMMENTARY:
Patient response and tolerance of side effects determine which drug class to use
Grant Hoekzema, MD
Mercy Family Medicine Residency, St. Louis, Mo
Although recent national guidelines for the management of COPD, such as the GOLD report, give more cohesiveness to treatment strategies for patients with COPD, there is still room for tailoring a treatment approach. I find that when choosing between beta-agonists and anticholinergics, patient response and tolerability of side effects determine what I use.
This Clinical Inquiry supports my clinical impression that neither class of drug is significantly superior to the other in regards to COPD outcome measures. In my experience, when neither drug offers a clear advantage, factors affecting compliance and tolerability tend to determine how effective it is for my patients. Therefore, a trial of either class seems reasonable at first and follow-up determines what is used in the long run.