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Anticholinergic Agents COMBINATION BRONCHODILATOR THERAPY
The key mechanism of anticholinergic medicationsappears to be the blocking of muscarinic receptors(M1, M2, and M3). By blocking acetylcholine-
• Combining bronchodilators with different
mediated bronchoconstriction, the end result
Side effects associated with anticholinergic therapy
• The combination of a ß2-agonist and an anti-
include dry mouth, glaucoma, and urinary retention.2
cholinergic may produce additional improvements inlung function and health status1
Use of Medications
• The safety of each component of the combination
therapy should be assessed in evaluating its
2-Agonists in Stable COPD
2 agonists primarily relax airway smooth muscle
by stimulating ß2-adrenergic receptors. This,
REMIND YOUR PATIENTS TO TAKE THEIR MEDICATION DAILY
in turn, increases cyclic adenosine monophosphate(AMP) and produces functional antagonismto bronchoconstriction.1Side effects are more frequent in oral therapy
than inhaled therapy. They include palpitations andpremature ventricular contractions, tremor, and
For a discussion of specific bronchodilator treatment
options for management of stable COPD, pleaserefer to the Global Initiative for Chronic ObstructiveLung Disease (GOLD) Executive Summary (updated
2006) in the Guidelines and Resources section of theGOLD Web site. This is available at www.goldcopd.org.
Theophyl ine agents may act as nonselective
phosphodiesterase inhibitors but have also been
1. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the
reported to have a range of nonbronchodilator
Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease
(Updated 2006). www.goldcopd.org. Accessed March 7, 2007. 2. Barnes PJ.
The role of anticholinergics in chronic obstructive pulmonary disease. Am J Med.
2004;117:24S-32S. 3. American Thoracic Society/European Respiratory Society Task
Theophylline requires careful dose management
Force. Standards for the diagnosis and management of patients with COPD (Internet).
Version 1.2. New York: American Thoracic Society; 2004 (updated September 8, 2005).
due to its potential toxicity and serious side effects,
www.thoracic.org/sections/copd/resources/copddoc.pdf. Accessed March 8, 2007. 4. Mahler DA, Wire P, Horstman D, et al. Effectiveness of fluticasone propionate and
including ventricular and atrial rhythm disturbances
salmeterol combination delivered via the Diskus device in the treatment of chronic
obstructive pulmonary disease. Am J Respir Crit Care Med. 2002;166:1084-1091. 5. Jones PW, Wil its LR, Burge PS, Calverley PM. Disease severity and the effect of
fluticasone propionate on chronic obstructive pulmonary disease exacerbations. Eur Respir J. 2003;21:68-73. 6. Calverley P, Pauwels R, Vestbo J, et al. Combined
salmeterol and fluticasone in the treatment of chronic obstructive pulmonary disease:
a randomised control ed trial. Lancet. 2003;361:449-456.
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A healthcare practitioner educational resource provided byBoehringer Ingelheim Pharmaceuticals, Inc.
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DM45624.qxp:DM45624 Meds 11/16/09 1:57 PM Page 4
USE OF MEDICATIONS IN THE OTHER AGENTS
to occur. Other topical side effects include
MANAGEMENT OF STABLE COPD
oropharyngeal candidiasis and hoarse voicedue to pharyngeal deposition.3
Although airway obstruction in COPD is onlypartial y reversible, pharmacological treatments may1:
The benefits of inhaled corticosteroids in treating
COPD are much less dramatic than those seen in
asthma. Their role in stable COPD management
is limited to symptomatic patients with COPD
Currently, only a few types of combination
with an FEV1<50% predicted (Stage III: Severe
medications are available. The following are
in treating patients who have experienced
The dose-response relationships and long-term
• Long-acting ß2-agonist and inhaled corticosteroid
safety of inhaled corticosteroids in COPD are
BRONCHODILATORS IN STABLE COPD
not known.1 Inhaled steroids are not approved
Side effects are dependent on the medications in the
combination1 and are described on pages3 to 5 in the specific sections for these medications.
• Bronchodilator medications are central to
Recommended Therapy at Each Stage of COPDa1
• The choice of ß2-agonist, anticholinergic,
theophylline, or combination therapy dependson availability and individual response in termsof symptom relief and side effects1
• Bronchodilators are prescribed as needed
or for maintenance therapy to prevent orreduce symptoms1
• Long-acting inhaled bronchodilators are more
effective and convenient than short-acting agents1
• Combining bronchodilators may improve
efficacy and decrease the risk of side effects
compared with increasing the dose of asingle bronchodilator1
a COPD definition includes FEV1/FVC<0.70 and post-bronchodilator FEV1 values as described in table. FEV1 = forced expiratory volume in 1second.
Pediatric Clinics Amsterdam Editorial Board Outcome of severe hypernatremia caused by rotavirus gastroenteritis M. P. Gruppen1 and P. Dahlem1 lopment. Also the MRI and EEGhad completely normalized. Editorial Office Case report Published by Pediatric events Kindergeneeskunde 5th International Symposium on Leukemia and Lymphoma Department of Pediatric Intensi
Published online May 11, 2004 2594±2597 Nucleic Acids Research, 2004, Vol. 32, No. 8Mapping of the second tetracycline binding site onthe ribosomal small subunit of E.coliMaria M. Anokhina1, Andrea Barta2, Knud H. Nierhaus3, Vera A. Spiridonova4 andAlexei M. Kopylov1,4,*1Department of Chemistry, Moscow State University, 119992 Moscow, Russian Federation, 2Institute ofBiochemistry, Universi