The MABA approach: a new option to improve bronchodilator therapy

Abstract

Recently, the results of an interesting systematic review have shown that the use of a combination of a long-acting β2-agonist (LABA) and a long-acting antimuscarinic agent (LAMA), the so called “dual” bronchodilator therapy, in stable moderate chronic obstructive pulmonary disease (COPD) patients is potentially a good pharmacological approach for the improvement of symptoms when they are not adequately controlled with tiotropium monotherapy [1]. Several studies have demonstrated a superior bronchodilation effect of combining a LABA with a LAMA compared with the individual agents alone, and that these combinations are well tolerated in patients with moderate to severe COPD [2]. Published evidence also indicates that “dual” bronchodilator therapies induce greater improvements in patient-centred outcomes such as dyspnoea, symptoms, rescue medication use and health-related quality of life than individual drugs used alone [3]. These findings are not surprising because the pharmacological rationale that supports this therapeutic possibility seems to be solid [4]. LABAs and LAMAs directly target airway smooth muscle working through different pathways [4, 5]. Moreover, several intriguing preclinical data support cross-activity of acetylcholine on the sympathetic system and adrenergic catecholamines on the parasympathetic (acetylcholine neurotransmission) system [4–6]. All this explains why the new executive summary of the Global Initiative for Chronic Obstructive Lung Disease recommends a combination of long-acting bronchodilators as a second choice in COPD patients who have significant symptoms but still a low risk of exacerbations, or have few symptoms but a high risk of exacerbations [7]. A combination of long-acting bronchodilators is a second choice also in patients who have many symptoms and a high risk of exacerbations, but it must be associated with an inhaled corticosteroid [7]. Nonetheless, there is still no unanimous agreement about …