Case Internal Medicine: 85 male with COPD.

An 85-year-old former smoker with moderate chronic obstructive pulmonary disease (stage II COPD, as measured by the Global Initiative for Chronic Obstructive Lung Disease) presents for routine follow-up.

He reports increasing dyspnea with exertion and a chronic, nonproductive cough.He currently takes fluticasone in combination with salmeterol as maintenance therapy and uses a short-acting beta-agonist albuterol inhaler as his rescue medication.

He has historically needed his rescue inhaler less than once a week, but for the past 3 months, he has needed it 2 to 3 times per day. He has been hospitalized for COPD exacerbations twice in the past 6 months.

Which one of the following medications should be added to this patient’s regimen to achieve better control of his symptoms?


Controller medications shown to be effective for chronic obstructive pulmonary disease include long-acting beta agonists, inhaled glucocorticoids, and long-acting anticholinergics, such as tiotropium.


Long-term use of tiotropium, a long-acting anticholinergic medication, has been shown to improve lung function, decrease dynamic hyperinflation, and decrease dyspnea and exacerbations in patients with chronic obstructive pulmonary disease (COPD). In a randomized, double-blind, placebo-controlled trial involving patients with COPD, tiotropium was associated with improved lung function, better quality of life, and decreased exacerbation frequency during the 4-year study period.

Tiotropium is not approved for acute bronchospasm and should be used with caution in patients with benign prostatic hypertrophy or bladder-neck obstruction.

If a patient is already taking an inhaled glucocorticoid, such as fluticasone, the addition of another inhaled glucocorticoid, such as budesonide, is not indicated.

Similarly, if a patient is already taking salmeterol, addition of another long-acting beta-agonist, such as formoterol, is not indicated.

Montelukast is a leukotriene-receptor antagonist that is used to treat asthma and seasonal allergies; it has not been shown to be effective in the treatment of COPD.

Chronic oral glucocorticoids, such as prednisone, should be avoided in the treatment of COPD until other controller medication options have been exhausted.


Tashkin DP et al. A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl J Med 2008 Oct 7; 359:1543.

Vogelmeier C et al. Tiotropium versus salmeterol for the prevention of exacerbations of COPD. N Engl J Med 2011 Mar 25; 364:1093.

Karner C and Cates CJ. Long-acting beta(2)-agonist in addition to tiotropium versus either tiotropium or long-acting beta(2)-agonist alone for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2012 Apr 20; 4

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