The Beta-Agonist Controversy - Impact In Copd

A cardinal diagnostic feature of asthma is the marked improvement in spirometric values that rapidly follows the aerosol administration of a β-adrenergic drug. The equally evident clinical benefit for a patient that is attained in treating an asthmatic exacerbation with a β-adrenergic bronchodilator provides an established and uncontested basis for the cornerstone role of these drugs in the short-term management of asthma. However, an unresolved controversy continues regarding the effectiveness and safety of β-agonist drugs in the daily routine management of chronic asthma, despite the recognition of their essential therapeutic value in exacerbations of asthma or in their ability to reverse or prevent occasional bronchospasm. 1 Skorodin M Pharmacotherapy for asthma and chronic obstructive pulmonary disease: current thinking, practices and controversies. Arch Intern Med. 1993; 153: 814-828 Crossref PubMed Google Scholar Unfortunately, the indications for their use in any phase of COPD are less clearly established. However, before discussing the information regarding β-agonist use in COPD, it is necessary to review the current concerns about β-agonist use in asthma. The differences in the therapeutic approaches to asthma and COPD are summarized in Table 1. Table 1Differences in Therapeutic Approaches to Asthma and COPD Drug Asthma COPD β-Agonists Aerosol Excellent response Slight to moderate response Long-acting May be useful Value not established Oral Rarely needed May be useful if patient cannot use aerosols Ipratropium Sometimes useful, eg, in smokers Excellent response in many patients Theophylline Sometimes useful Often useful, particularly if patient cannot use aerosols Corticosteroids Intravenous Essential for severe exacerbations May be useful in exacerbations Oral Essential for severe asthma May be useful in 10-30% of cases Aerosol Essential if regular β-agonist aerosol is used Value not established, but may be useful in some cases Cromolyn/nedocromil Useful in specific cases, eg, exercise-induced asthma Value not established; unlikely to be useful in most cases unless asthmatic component is pronounced Antibiotics Rarely needed Needed for infectious exacerbations Mucokinetics Value not established Indicated in bronchitis Long-term oxygen Rarely needed Often needed in severe cases Open table in a new tab