Medications

Medications

Anticholinergic Agents

Anticholinergic agents relax the bronchial muscles. They are generally inhaled and act as a bronchodilator over time.

Brands and Benefits. Anticholinergics used for COLD include ipratropium (Atrovent) and tiotropium (Spiriva). Ipratropium is the older agent, and experts recommend it as the first choice in treating COLD. It has a very slow onset and can be used as maintenance therapy for people with emphysema and chronic bronchitis. Anticholinergic agents have few severe side effects. They are less likely to impair sleep than the other standard inhaled medications.

A patient should not take more than 12 inhalations per day. Tiotropium (Spiriva) requires only one daily inhalation, and evidence suggests it may be particularly effective for COLD patients. A single inhaler containing both ipratropium and the common beta2-agonist albuterol (Combivent) may prove to be better than either medicine alone. Anticholinergics target the central airways, and beta agonists target the smaller airways, thus explaining, according to current theory, the additive benefits of the combination.

Side Effects. Some common side effects of anticholinergic agents include blurred vision and urinary obstruction. Patients with allergies to soy or peanut products should not use these drugs. Those with glaucoma should be very careful to prevent spraying the medication in the eye, as this could worsen their glaucoma.

Beta2-Agonists

Beta2-agonists are the most widely prescribed bronchodilators, most often for asthma. These drugs are generally inhaled using a metered-dose inhaler (MDI) or nebulizer. A nebulizer delivers a larger dose of the drug and is more expensive than the MDI. Experts recommend the inhaler for most patients and suggest reserving the nebulizer for patients with severe disease who are unable to use the MDI. Survival rates are similar. Beta2-agonists are also available in oral forms, although oral forms have more side effects than the inhaled beta2-agonists, and they take longer to start working. Oral beta2-agonists should be reserved only for patients who cannot use inhaled forms.

Short-Acting Beta2-agonists. Short-acting bronchodilators are the primary agents for most COLD patients. Albuterol (Proventil, Ventolin) is the standard short-acting beta2-agonist. Others include isoproterenol (Isuprel, Norisodrine, Medihaler-Iso), metaproterenol (Alupent, Metaprel), pirbuterol (Maxair), terbutaline (Brethine, Brethaire, Bricanyl), bitolterol (Tornalate), and isoetharine (Bronkometer, Bronkosol), which is available in nebulizers. Newer beta2-agonists, including levalbuterol (Xopenex), have more specific actions than the standard agents. Most are administered through inhalation and are effective for 3 to 6 hours.