Commentary

β₂ agonists are frequently used as a first line treatment for COPD to maximise bronchodilation and minimise dyspnoea.¹ The use of short acting versus long acting β₂ agonists remains somewhat controversial because bronchodilators cause only small increases in FEV₁. These drugs improve symptoms by reducing hyperinflation and thus reducing dyspnoea, but often with little effect on spirometry measurements.² The review by Ram and Sestini attempted to clarify the effects of ISABAs compared with placebo.

Only 13 trials met the inclusion criteria. All were randomised crossover trials that assessed ISABAs alone or in combination with other drugs. Anticholinergic drugs such as ipratropium bromide have generally been considered more effective for treatment of COPD because they have fewer side effects, slower onset of action, and longer duration of action.³ Ram and Sestini suggest that ISABAs offer an inexpensive and effective treatment for the management of stable COPD, although the practical issue of the effectiveness of ISABAs compared with other bronchodilators (eg, long acting β₂ agonists) remains unanswered. However, many patients with COPD have specific intolerances and contraindications that require customising COPD management using a stepwise approach based on severity of airway symptoms. Thus, primary care providers should continue to tailor selection of bronchodilators for treatment of COPD based on the individual requirements of patients. Use of any treatment should, of course, include close monitoring of patient symptoms, FEV₁, exercise tolerance, oxygen saturation, and responses to bronchodilator treatment.