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Randomised controlled trial
Tiotropium is superior to salmeterol in reducing frequency of exacerbations: but the effect of adding tiotropium to the combination of inhaled corticosteroid and long-acting β(2)-agonist remains unclear
  1. Rick Hodder
  1. University of Ottawa, The Ottawa Hospital, Ottawa, Canada
  1. Correspondence to Rick Hodder
    University of Ottawa, The Ottawa Hospital, 1053 Carling Ave, Ottawa, ON K1Y4E9, Canada; rhodder{at}

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Clinical practice guidelines (CPG) for the management of stable chronic obstructive pulmonary disease (COPD) recommend the addition of long-acting bronchodilators for patients who remain symptomatic despite use of short-acting bronchodilators.1 Whether a long-acting muscarinic antagonist (anticholinergic) bronchodilator (LAMA) such as tiotropium or a long-acting β2-agonist bronchodilator (LABA) such as salmeterol, formoterol or indacaterol should be used as initial therapy is a matter of debate.

If symptoms persist despite the use of tiotropium, CPGs recommend adding a LABA. In practice, the LABA added usually includes inhaled corticosteroid (ICS) as a combination inhaler (LABA/ICS: salmeterol/fluticasone or formoterol/budesonide). Occasionally, a LABA/ICS is used instead of tiotropium as initial therapy, although this is not recommended by evidence-based CPGs. Finally, although commonly used for moderate-to-severe COPD, there has been little research into the effectiveness of so-called ‘triple therapy’, namely a LABA/ICS plus LAMA. This commentary examines two recent studies that have attempted to clarify these issues.


In the first study, Vogelmeier et al performed a 1 year, multicentre, randomised placebo-controlled, blinded, double dummy trial comparing the effectiveness of either tiotropium 18 …

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  • Competing interests RH has received research grants, consulting and speaking honoraria from AstraZeneca, Boehringer-Ingelheim, GlaxoSmithKline, Novartis, Nycomed.