O1.2.3 Long-acting bronchodilator combinations

A small number of studies have found that a combination of a long-acting anticholinergic and long-acting beta-agonist is better than either monotherapy (Chen et al., 2008) [evidence level I]. Once daily administration of tiotropium and once or twice daily formoterol significantly improves FEV₁ compared to tiotropium alone and also decreases daytime rescue inhaler use (mean puff per day tiotropium alone = 2.41, formoterol alone = 2.37, combination = 1.81). Similar effects have been found with tiotropium and salmeterol, although in small numbers and with co-administration of inhaled glucocorticoids. A further study to evaluate the best timing for combination therapy confirmed the superior benefit of combination therapy using daily tiotropium and twice-daily formoterol (Terzano et al., 2008) [evidence level II]. Whether tiotropium was administered in the morning or evening did not seem to impact on bronchodilatation, breathlessness or use of rescue inhalers. There are currently no data on the combination of tiotropium and indacaterol in COPD.