Dr Nicola Hanania: Why Combination Bronchodilators Should Be First-Line Therapy

November 7, 2020

Combination bronchodilators are available and have been shown to improve both symptoms and lung function, explained Nicola Hanania, MD, MS, of Baylor College of Medicine.

Combination bronchodilators are available, and they have been shown to improve both symptoms and lung function, as well as reduce exacerbation. So, why not use them, asked Nicola Hanania, MD, MS, pulmonary critical care physician and director, Airway Clinical Research Center, Baylor College of Medicine, Houston, Texas.


How does bronchodilator monotherapy work versus combination therapy?

So, in monotherapy, a bronchodilator works through one mechanism. So, if you imagine the airway: smooth muscles are controlled by the autonomic nervous system, and the autonomic nervous system has both sympathetic and parasympathetic drivers. Activating the sympathetic driver by using beta-agonists can cause smooth muscle relaxation. Blocking the cholinergic pathway, where you remove the what we call the cholinergic tone on the muscles, can also cause bronchodilation—but also may have other effects on mucus production.

So, a single bronchodilator usually causes smooth muscle relaxation. We believe adding 2 bronchodilators may work—maybe not synergistically, but maybe additive—although there are data suggesting that they actually work better than just each one alone, when you add both. And they may actually have a synergistic effect. That still needs to be further clarified.

Why should combination bronchodilators be considered for first-line therapy?

It is a hot topic, and it's actually embraced now by the American Thoracic Society, pharmacologic guidelines, clinical practice guidelines—based on evidence. There's quite a bit of accumulating evidence from clinical trials and meta analysis published showing that adding a LABA [long-acting beta-agonist] and a LAMA [long-acting muscarinic antagonist] in a symptomatic patient with COPD improves symptoms, improve lung function, and may have a superior effect on reduction of exacerbation.

So, why not? We have these drugs, they are available, there are actually 5 of them in the US. And if the cost is not an issue? Safety is definitely not an issue. There are several papers published now that they are fairly safe in the appropriate population. Of course, not every person is the same as the other. Why not start with a LABA/LAMA if you get a better effect with these 2—especially [because] you're not giving more than one inhaler, they’re all combined—than using just one alone?