Stephen I. Rennard, MD

Chronic obstructive pulmonary disease(COPD) is the fourth leadingcause of chronic morbidity and mortalityin the United States.1 Its prevalenceand impact are increasing,and the World Bank/World HealthOrganization has projected that it willrank fifth in 2020 as a global burdenof disease.2,3 The economic and publichealth impact of COPD is staggering,because this chronic conditionrequires long-term care, frequentoffice visits, and use ofemergency department and hospitalservices. Thus, there is a pressingneed to discover new therapies thatcontrol symptoms and prevent diseaseprogression.

ABSTRACT: Bronchodilators are central to COPD symptom management; current options include the anticholinergic ipratropium, short- and long-acting ß2-agonists, and theophylline. Tiotropium, which is not yet available in the United States, may become a useful addition to the armamentarium. Novel phosphodiesterase 4 inhibitors with both anti-inflammatory and bronchodilatory effects, including roflumilast, piclamilast, and cilomilast, are being investigated. Combination therapy with bronchodilators that have different mechanisms and durations of action may prove key in achieving the greatest symptom control with the fewest side effects. For example, prescribing a first-generation ß2-adrenergic agonist, such as albuterol, together with an antimuscarinic agent is reasonable from the standpoints of both efficacy and safety.