Optimizing maintenance therapy for chronic obstructive pulmonary disease: strategies for improving patient-centered outcomes.
BACKGROUND
Chronic obstructive pulmonary disease (COPD) is associated with substantial morbidity and mortality. Published practice guidelines and treatment algorithms for COPD are designed to increase awareness of the problem and improve patient care; however, <40% of subjects diagnosed with COPD are receiving appropriate maintenance therapy.


OBJECTIVE
This paper reviews the use of maintenance therapy in COPD and examines the optimal timing for initiating such therapy based on the available literature.


METHODS
Relevant publications were identified through a search of MEDLINE (1995-May 2007) using the terms COPD, guidelines, treatment, maintenance therapy, bronchodilator, ipratropium, tiotropium, beta-agonist, salmeterol, and inhaled corticosteroid. English-language publications discussing pharmacologic maintenance therapy for COPD, including practice statements/guidelines, randomized controlled clinical trials, systematic reviews, and meta-analyses, with a focus on agents currently approved for use in the United States, were selected for inclusion.


RESULTS
Although guidelines and algorithms agree on the importance of regularly scheduled maintenance therapy to reduce symptoms of COPD, minimize activity limitations, and improve health status, the timing of the initiation of such therapy is debatable. In most instances, maintenance medications, which include long-acting beta(2)-agonists, long-acting anticholinergics, and combination products, are prescribed late in the disease process and mainly for patients with severe disease. However, there is increasing evidence that the use of maintenance therapy early in the disease process may be associated with improvements in such outcomes as lung function, symptoms, exercise tolerance, exacerbations of COPD, and quality of life.


CONCLUSIONS
The high burden associated with COPD highlights the need to initiate maintenance therapy before a substantial decline in lung function has occurred.
Hanania
Nicola A
NA
Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, Texas 77030, USA. hanania@bcm.tmc.edu
D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000627:therapeutic use*; D000318:Adrenergic beta-Agonists / Q000008:administration & dosage / Q000627:therapeutic use*; D001993:Bronchodilator Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D018680:Cholinergic Antagonists / Q000008:administration & dosage / Q000627:therapeutic use*; D003692:Delayed-Action Preparations; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D006801:Humans; D018802:Patient-Centered Care; D029424:Pulmonary Disease, Chronic Obstructive / Q000188:drug therapy*; D016896:Treatment Outcome
D000305:Adrenal Cortex Hormones; D000318:Adrenergic beta-Agonists; D001993:Bronchodilator Agents; D018680:Cholinergic Antagonists; D003692:Delayed-Action Preparations