Initial inhaler choice in COPD: Real-world evidence

Long-acting bronchodilators are the mainstay of inhaled therapy in COPD. Both long-acting β-agonists (LABA) and long-acting muscarinic antagonists (LAMA) are effective at reducing breathlessness and exacerbation frequency, with LAMA being the more effective of the two classes [1]. The Global Initiative for Chronic Obstructive Lung Disease advises that inhaled corticosteroids (ICS) are reserved for those who exacerbate more frequently and preferably after the addition of dual long-acting bronchodilators [2]. Some people with COPD benefit from ICS, and there is evidence that blood eosinophil count is a useful biomarker to highlight who might benefit [3]. ICS are known to increase the risk of pneumonia in people with COPD [4] but despite the guidelines, many people with COPD are prescribed LABA/ICS combinations as initial inhaled therapy [5]. Suissa et al. [6] reported real-world evidence comparing LABA/ICS with LAMA as the initial treatment of COPD, stratified by blood eosinophil count, detailing both the benefits for exacerbation frequency and risk of pneumonia with each treatment strategy.