Time to question long-term safety of routine scheduled inhaled beta-2-agonist treatment for COPD.

摘要

How many times have I heard in my general medical clinic a patient complain that he has stopped using his anti-cholinergic inhaler because it doesn't seem to work as well as his beta-agonist inhaler? On further questioning such patients often cite the lack of an immediate improvement in ease of breathing as their criterion for efficacy. Explaining how both inhalers may help them, but in different time frames, usually will be enough encouragement to get them to comply. I fear, however, that my patients are not the only ones who are transfixed on short-term symptomatic relief to the exclusion of long-term benefit (or harm). We physicians as well as trialists and policy makers are often complicit in this short sightedness.The meta-analysis by Salpeter et al. focuses our attention on longer-term consequences of inhaled bronchodilator therapy for COPD. Such drugs are commonly used, and guidelines recommended them with little direction as to whether anticholinergic or beta-agonists or both should be used. For example, in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline "the choice between beta2-agonist, anticholinergic, theophylline, or combination therapy depends on availability and individual response in terms of symptom relief and side effects" and "bronchodilators are prescribed on an as-needed or on a regular basis to prevent or reduce symptoms."