Inhaled Beta Agonists Research Articles

Indacaterol: A novel, Inhaled Beta-2 agonist for COPD

Indacaterol: A novel, Inhaled Beta-2 agonist for COPD

Improving Asthma Care in the Hospital: an Overview of Treatments and Quality Improvement Interventions for Children Hospitalized for Status Asthmaticus

Asthma is one of the leading causes of pediatric hospitalization in the USA. This review summarizes evidence-based practices for inpatient pediatric asthma treatment, including routine care, care escalation, and discharge care, along with established and emerging inpatient quality improvement approaches. Intermittent inhaled beta agonists, systemic steroids, and, for patients with low oxygen saturation, supplemental oxygen remain the cornerstones of routine inpatient asthma care. Compared to nebulization, metered-dose inhaler delivery of intermittent beta agonist therapy is more effective and underused. Oral prednisone produces similar clinical outcomes and is more cost-effective when compared with intravenous methylprednisolone. Standardized respiratory assessment scores should supplement clinical judgment in evaluating response to therapy. There are no studies that demonstrate the effectiveness of routine adjuvant anticholinergic therapy outside of the emergency room, though it may be effective in a subset of inpatients. Evidence for inpatient care escalation is limited. With respect to discharge care, simple provision of asthma care plans does not appear to reduce readmissions, though individually tailored asthma care plans remain a standard of discharge care, along with systemic steroids, beta agonists, and, when indicated, inhaled corticosteroids. To avoid medication access barriers for high-risk patients, clinicians can ensure that discharge medications are in-hand before the patient leaves the hospital. A number of quality improvement strategies have shown promise in the inpatient setting. Clinical pathways reduce length of stay and costs associated with care without an associated increase in readmissions. Inpatient family education programs can be effective but should incorporate multiple strategies, including individualized management strategies and post-discharge follow-up. Inpatient care also serves as a useful opportunity to assess home environmental risk and to refer high-risk families to outpatient and community resources.

Combination budesonide/formoterol inhaler as maintenance and reliever therapy in Māori with asthma.

There are significant health disparities between Māori and non-Māori with asthma, a pattern seen between other ethnic populations. This study investigates outcomes for Māori in a randomized controlled trial (RCT) of combination budesonide/formoterol inhaler therapy in asthma. This 24-week multicentre RCT recruited 303 adult asthma patients, 44 of whom were Māori. Participants were randomized to the single combination budesonide/formoterol inhaler as maintenance and reliever therapy ('SMART') regimen or 'standard' regimen (combination budesonide/formoterol inhaler for maintenance and salbutamol as reliever). Outcomes included patterns of beta-agonist inhaler use including 'high use' of reliever therapy (>8 actuations of budesonide/formoterol in excess of four maintenance doses per day for SMART and >16 actuations per day of salbutamol for standard). Differences in outcomes for Māori versus non-Māori were assessed using an interaction term between ethnicity and treatment. With adjustment for ethnicity, the SMART group had fewer days of high use (relative rate (RR) 0.57 (95% confidence interval (CI): 0.38-0.85)), days of high use without medical review within 48 h (RR 0.49 (95% CI: 0.32-0.75)) and severe exacerbations (RR 0.54 (95% CI: 0.36-0.81)) compared with standard. The magnitude of the benefit from the SMART regimen was similar in Māori and non-Māori. Regardless of treatment regimen, Māori demonstrated more days of high use, high use without medical review and underuse of maintenance therapy. The SMART regimen has a favourable risk/benefit profile in Māori. Days of high use, days of high use without medical review and underuse of maintenance treatment were greater in Māori, regardless of treatment regimen.

Bronchodilator effect of single-dose formoterol administered by pressurized metered-dose inhaler in children with asthma aged 6 to <12 years receiving budesonide

Dose-response of formoterol via pressurized metered-dose inhaler (pMDI) has not been determined in asthmatic pediatric patients aged 6 to <12 years. This study was designed to assess the bronchodilating dose-response of three formoterol pMDI doses in children with stable asthma aged 6 to <12 years receiving twice-daily (b.i.d.) budesonide 160 micrograms. A U.S., multicenter, five-way crossover study compared single doses of formoterol, a long-acting beta-agonist, via pMDI (2.25, 4.5, and 9 micrograms) or dry powder inhaler (12 micrograms; active comparator) and placebo, with a 3- to 14-day washout period between doses. Budesonide pMDI 160 micrograms, an inhaled corticosteroid, was given b.i.d. throughout the study. Fifty-four pediatric patients (mean age, 9.2 years; mean asthma history, 6.1 years) were randomized. All formoterol doses showed significantly higher average 12-hour forced expiratory volume in 1 second (FEV1; area under the curve) versus placebo (primary efficacy). Formoterol pMDI 4.5 and 9 micrograms showed significantly greater average 12-hour FEV1 than formoterol 2.25 micrograms (p = 0.0007 and p = 0.0001, respectively). Formoterol also resulted in significant improvement in maximum FEV1 during the 12-hour treatment period (secondary efficacy) with formoterol 4.5-, 9-, and 12-microgram doses versus placebo and the formoterol 2.25-microgram dose. Bronchodilation was not maintained during the 12-hour dosing interval with formoterol 2.25 micrograms. No serious adverse events were reported. Formoterol pMDI showed generally dose-proportional pharmacokinetics to 9 micrograms, as determined by urinary excretion. Single doses of formoterol pMDI showed a dose-response, with formoterol 9 micrograms exhibiting a maximum response, in pediatric patients aged 6 to <12 years with persistent stable asthma maintained on b.i.d. budesonide pMDI 160 micrograms. Clinical trial NCT01136655, www.clinicaltrials.gov.

Magnesium for acute exacerbation of chronic obstructive pulmonary disease: A systematic review of randomised trials.

The efficacy of magnesium sulphate in chronic obstructive pulmonary disease (COPD) was assessed by conducting a systematic review of published randomized clinical trials through extensive searches in MEDLINE and SCOPUS with no date limits, as well as manual review of journals. Outcome measures varied depending on route(s) of administration of magnesium sulphate and medications co-administered. Risk of bias was evaluated and quality of evidence was graded. Four (4) randomized trials were included. All trials had a moderate risk of bias and were of average methodological quality. Magnesium sulphate given intravenously did not seem to have an immediate bronchodilatory effect; however it appears to potentiate the bronchodilatory effect of inhaled beta-2 agonists. Increase in peak expiratory flow rate (PEFR) at 30 and 45 min was greater in those who received magnesium sulphate compared to placebo (P = 0.03), although the mean percentage change in PEFR was just 24%, without significant differences in dyspnoea scores, hospital admission rates, or emergency department readmission rates compared to placebo. Nebulized magnesium sulphate with salbutamol versus nebulized salbutamol with saline placebo showed no significant differences is forced expiratory volume in 1 s (FEV1) measured at 90 min after adjustment for baseline FEV1 (P = 0.34) or differences in the need for hospital admission. Combined inhalational and intravenous magnesium sulphate versus intravenous saline placebo and nebulized ipratropium bromide were comparable in terms of hospital admission, intubation and death, but the ipratropium bromide group showed better bronchodilator effect and improvement in arterial blood gas parameters. Overall, trial evidence for trial evidence for magnesium sulphate in acute exacerbation of COPD is poor, and further well-designed trials are needed.

Combination ICS/fast-onset LABA inhaler as maintenance and reliever therapy: the future for uncontrolled adult asthma?

In the Single combination inhaler as Maintenance And Reliever Therapy (SMART) regimen, asthma patients use a corticosteroid/fast-onset long-acting beta-agonist inhaler as both regular maintenance and reliever therapy. In this multicenter, double-blind randomized controlled trial, Papi et al. have demonstrated that treatment with the combination beclometasone/formoterol hydrofluoroalkane (HFA)-MDI when used as both maintenance and reliever therapy significantly prolongs the time to the first severe asthma exacerbation and reduces severe exacerbations compared with the same fixed dose of maintenance beclometasone/formoterol HFA-MDI with salbutamol MDI for relief. These findings are consistent with those of the prior studies of the SMART regimen with the budesonide/formoterol DPI and extend the evidence for use of the SMART regimen to the extrafine beclometasone/formoterol HFA-MDI, to patients with high baseline reliever use, and to patients in whom the SMART regimen results in a step up, step down or no change in baseline inhaled corticosteroid dose.

Long-term Mortality among Adults with Asthma: A 25-Year Follow-up of 1,075 Outpatients with Asthma: Ali Z, Dirks CG, Ulrik CS. Chest 2013;143:1649–55.

This prospective case-control study from Denmark recruited 1075 adult patients with asthma from an outpatient allergy clinic from 1974–1990 (and an equal number of age- and sex-matched controls) and followed their outcomes in terms of five major categories of cause of mortality through the end of 2011. Subjects were included based on typical clinical history, reversibility in forced expiratory volume in 1 s (FEV1) > 15% after administration of standardized doses of inhaled beta agonist or oral corticosteroid, or diurnal variability in peak expiratory flow >20%. Subjects were further stratified as having allergic vs. nonallergic asthma on the basis of total serum immunoglobulin E, history of extrinsic asthma, skin prick tests, radioallergosorbent assays, and bronchial provocation tests. Subject and control mortality outcomes were obtained from the Danish Death Register and Danish National Board of Health, and classified into five categories including status asthmaticus, obstructive lung disease not classified as status asthmaticus, cardiovascular disease, malignant neoplasm, and other causes.

Pharmacogenetics and the Development of Personalized Approaches for Combination Therapy in Asthma

Asthma is a common, chronic disease of the airways that is treated with a combination of different therapies. The combination of LABA and ICS therapy results in a synergistic interaction that is efficacious in improving asthma symptom control; however, genetic variation has the potential to alter therapeutic efficacy. Both agents mediate complex molecular pathways consisting of gene variation that has been investigated with the analysis of candidate genes in the β2-adrenergic receptor and glucocorticoid pathway. These pharmacogenetic studies have been limited to retrospective analyses of clinical trial cohorts and a small number of prospective, genotype-stratified trials. More recently, genome-wide association studies in combination with replication in additional cohorts and in vitro cell-based models have been used to identify novel pathway-related pharmacogenetic variations. This review of the pharmacogenetics of the β2-adrenergic receptor and glucocorticoid pathways highlights the genotypic effects of variation in multiple genes from interacting pathways which may contribute to differential responses to inhaled beta agonists and glucocorticoids. As our understanding of these genetic mechanisms improves, panels of biomarkers may be developed to determine which combination therapies are the most effective with the least risk to an individual asthma patient. Before we can usher in an era of personalized medicine for asthma, it is first important to improve our ability to analyze large volumes of genetic data in large clinical trial cohorts using a combination of study designs, analytical methods, and in vitro functional studies.

What we should learn from the London Olympics

The London Olympics have just finished. Official reports will soon become available on how many athletes participating in the games had asthma. However, as in the past, prevalence data will often be deducted by the number of athletes using inhaled beta-2 agonists that, according to the new 2012 World Anti-Doping Agency (WADA) rules, were on this occasion permitted for all the most commonly used short-acting and long-acting drugs, just following a declaration of use made by the athletes themselves. This self-reporting will largely influence the accuracy of estimates, which will not distinguish between clinical asthma and exercise-induced bronchoconstriction (EIB) without clinical asthma, as recently requested.

Beta-Blocker Therapy: Too Little in COPD, Too Soon in ACS

ESTES PARK, COLO. – Beta-blockers may be underprescribed in the setting of chronic obstructive pulmonary disease, yet overused in the early treatment of acute myocardial infarction, recent surprising evidence suggests. Most physicians avoid prescribing beta-blockers in patients with COPD, even in patients with concomitant cardiovascular disease, because of worries about triggering bronchospasm and perhaps blocking the bronchodilating benefi ts of beta-agonist inhaler therapy. But data from a Scottish retrospective cohort study strongly suggest these concerns are misplaced, asserted Dr. Mel L. Anderson, chief of the hospital medicine section and associate chief of the medical service at the Denver VA Medical Center. Investigators working with the Tayside Respiratory Disease Information System (TARDIS) recently reported on 5,977 patients above age 50 with confi rmed COPD who were followed for a mean of 4.4 years. Patients on a beta-blocker plus various combinations of respiratory medications had a 22% decreased risk of all-cause mortality and a 50% reduction in the risk of hospitalizations for COPD during the follow-up period. The mortality benefi t associated with beta-blocker therapy proved independent of the presence or absence of overt cardiovascular disease. “Yes, this is an observational study and so you have to worry about selection bias, but if anything, it should at least make you feel comfortable that it’s safe to off er beta-blocker therapy to COPD patients, provided you’re sure they don’t have asthma,” Dr. Anderson said at a conference on internal medicine sponsored by the University of Colorado. He also highlighted beta-blockers’ widespread inappropriate use in the early treatment of MI in patients with one or more risk factors for cardiogenic shock. Investigators studied outcomes in 34,661 patients with ST elevation MI (STEMI) and non-ST-segment MI (nonSTEMI) who received beta-blocker therapy within the fi rst 24 hours after MI presentation at 291 participating U.S. hospitals. The relevant American College of Cardiology/American Heart Association Guidelines for Unstable Angina/NonSTEMI and STEMI recommend caution in giving beta-blockers in the fi rst 24 hours in patients with risk factors for cardiogenic shock. Yet in the ACTION Registry-GWTG study, 45% of the STEMI patients treated with early betablockers and 63% of early beta-blocker recipients with non-STEMI had one or more cardiogenic shock risk factors. Moreover, the ACTION Registry data demonstrated that early beta-blocker therapy in patients with risk factors for cardiogenic shock was associated with signifi cantly worse outcomes. For example, the combined rate of in-hospital cardiogenic shock or death was 1.3% in beta-blocker recipients with no shock risk factors, 4.8% in those with one of the risk factors, and 8.1% in those with two or more (Am. Heart J. 2011;161:864-70). The cardiogenic shock risk factors that grew out of the Clopidogrel and Metoprolol in Myocardial Infarction Trial (COMMIT) study are age greater than 70 years, systolic blood pressure below 120 mm Hg at presentation, a heart rate in excess of 110 bpm, and 12 hours or longer since symptom onset in STEMI patients. Dr. Anderson reported having no fi nancial confl ict of interest. CfA

Determinants of Prescribing Inhaled Long-Acting Beta-Agonist Bronchodilators As Monotherapy to Adults with Asthma

Determinants of Prescribing Inhaled Long-Acting Beta-Agonist Bronchodilators As Monotherapy to Adults with Asthma

Ivacaftor: A Novel Gene-Based Therapeutic Approach for Cystic Fibrosis

Ivacaftor is a new therapeutic agent that acts at the cystic fibrosis transmembrane conductance regulator (CFTR) channel to alter activity. It is approved for use in patients 6 years and older with cystic fibrosis who have at least 1 G551D mutation in the CFTR gene. It is unlike any other current pharmacologic agent for cystic fibrosis in that it specifically targets the gene defect associated with cystic fibrosis as opposed to treating resulting symptomology. Mucoactive agents, antibiotics, inhaled beta agonists, and other anti-inflammatory agents are currently the mainstay of cystic fibrosis treatment but can be associated with several side effects in addition to cumbersome frequency of administration. Ivacaftor's oral dosing regimen offers a more convenient treatment option. However, it is associated with significant drug-drug interactions.

389 Is the Higher Prevalence of Asthmatic Symptoms following Preterm Birth Restricted to Childhood?

Background and AimPreterm birth is associated with increased risk of asthmatic symptoms in childhood, but it seems uncertain whether this association persists into adulthood. We have investigated the association between...

Characterization of patients admitted to intensive care unit directly from emergency department

Results In the course of three months, 49 patients were admitted to the ICU via the ED. Average length of admission was 3.1 days. Main conditions were divided into seven subgroups; drug intoxication (n=13), respiratory insufficiency (n=11), GIhaemorrhage (n=6), high-pressure lung oedema (n=3), electrolyte disturbances (n=3), septic shock (n=3) and others (n=10). Treatments primarily used were, fluid/electrolyte therapy (n=29), broad-spectrum antibiotics (n=24), intubation (n=12), blood component therapy (n=11), NIV treatment (n=10), corticosteroids (n=10), beta-agonist inhalation treatment (n=7), vasopressor drugs (n=8), activated charcoal (n=9), diuretics (n=10), and others (n=52). In the subgroup of drug intoxication, 69% patients received activated charcoal. The remaining 31% were either unconscious and could not cooperate to place a gastric tube/drink the charcoal, or came to the ED too late, with activated charcoal having no effect. 69% of the patients also expressed that the incident was an attempt at suicide.

Chronic obstructive pulmonary disease: a slowly progressive cardiovascular disease masked by its pulmonary effects?

Chronic obstructive pulmonary disease: a slowly progressive cardiovascular disease masked by its pulmonary effects?

Drug utilization and asthma control among young Danish adults with asthma – analyses of trends and determinants

UNLABELLED This PhD thesis was performed during my employment at the Research Unit of General Practice in Odense, University of Southern Denmark. It comprises an overview of three papers, all published or submitted for publication in international peer-reviewed scientific journals. BACKGROUND Observational studies have revealed inadequate use of inhaled corticosteroids (ICS) among asthmatics. However, only limited data exist on whether ICS usage has changed over time. In addition, improved knowledge is needed on factors associated with ICS use and asthma control in order to identify subjects at risk of being inadequately treated. AIMS Among young adult Danish asthmatics we aimed: To investigate trends in ICS use and factors associated with ICS use during 1997-2006 (Study I). To investigate associations between socioeconomic status (education and income) and ICS use, and whether these associations were consistent over time during 1997-2005 (Study II). To investigate whether particular prescribing patterns of anti-asthmatic drugs were associated with clinically uncontrolled asthma (Study III). METHODS Three studies were carried out among Danish users of anti-asthmatic drugs aged 18-44 years. Study I (N = 106 757) and Study II (N = 97 665) were longitudinal studies based on repeated annual cross-sectional analyses on national register data. Study III (N = 357) was a cross-sectional study based on register and clinical data from a municipal cohort from Odense, Denmark. RESULTS Study I: We observed an annual increase in one year prevalence of ICS use from 67% in 2001 to 77% in 2006, occurring concurrently with the introduction of fixed dose combination therapy with ICS and inhaled long-acting beta-2-agonists. Still some 20-30% of subjects with a massive annual IBA consumption were not prescribed ICS. Factors associated with ICS use were high annual use of inhaled beta-2-agonists (IBA), female gender, age 18-24 years, use of leukotriene receptor antagonists, and use of drugs for rhinitis and specific immune therapy. Study II: High levels of education (OR 1.46, 95% CI 1.40-1.51) and income (OR 1.10, 95% CI 1.06-1.14) were found to be positively associated with ICS use with the most pronounced impact among 35-44 year-olds. Higher education showed an almost constant association with ICS use each year throughout the entire observation period, but high income did not demonstrate any statistically significant association with ICS use before 2001 (OR 1.10, 95% CI 1.02-1.18) with increasing ORs observed each year hereafter (OR 1.30, 95% CI 1.20-1.40 in 2005). Study III: A total of 96 of the clinically assessed subjects (26.9%) had uncontrolled asthma. An increasing association between uncontrolled asthma and an increasing annual quantity of inhaled short-acting beta-2-agonists (SABA) usage was demonstrated. Due to a substantial overlap in levels of SABA use among controlled and uncontrolled asthmatics this association was not strong enough to allow conclusions on individual asthma patients. CONCLUSION The results support previous findings by demonstrating a continuing inadequate use of ICS among young adult asthmatics with a consistent and high use of reliever therapy, which was associated with uncontrolled asthma. This apparent over-reliance on reliever therapy and possible non-adherence to ICS may indicate inefficient guideline implementation among patients and physicians, leaving room for further improvement. The clear indications of a socioeconomic gradient in ICS use further emphasizes that knowledge of patient-related factors associated with asthma treatment and asthma control is imperative for health care professionals to be able to identify subjects deserving special attention.

Asthma and risk of brain cancer in children

Little is known about the causes of central nervous system tumors in children. An inverse association between asthma and brain cancer was found in adults, but there is a dearth of studies in children. The goal of this study was to evaluate the association between asthma and brain cancer in children. Two hundred and seventy-two cases of children with brain tumor diagnosed between 0 and 14 years of age in the Province of Québec, Canada, between 1980 and 1999 and 272 incidence density-matched controls were included in the study. The parents of cases and controls were interviewed by phone using structured questionnaires. Besides asthma in children, family history of asthma, the presence of other atopies, and medication intake were also investigated. Conditional logistic regression was used to analyze the data. Brain tumor risk was decreased in children with asthma (OR, 0.55; CI 95%, 0.33-0.93), with eczema (OR, 0.52; CI 95%, 0.17-1.57), and with both asthma and eczema (OR, 0.76; CI 95%, 0.18-3.2). Maternal or sibling asthma did not modify the effect of asthma on central nervous system (CNS) tumors, while father's asthma seemed to increase the risk, but numbers were small. Antiasthma medications such as inhaled corticosteroid and beta agonists seemed to increase the risk of CNS tumors (OR for steroids, 2.55; CI 95%, 0.79-8.20 and OR for inhaled beta agonist, 1.62; CI 95%, 0.57-4.63). This study strengthens the hypothesis of inverse association between asthma and brain cancer in children, but family history and medications for asthma need further investigation.

Effect of theophylline on exercise capacity in COPD patients treated with combination long-acting bronchodilator therapy: a pilot study

BackgroundMany patients with chronic obstructive pulmonary disease continue to experience significant functional limitation despite the use of both long-acting anticholinergic and beta-agonist inhalers. Theophylline is a widely available medication which may further improve lung function and exercise performance. Previous studies evaluating the effects of theophylline on exercise capacity in chronic obstructive pulmonary disease (COPD) have demonstrated heterogeneous results.MethodsWe performed a randomized placebo-controlled double-blind pilot study assessing the effects of theophylline on constant load exercise duration and lung function, involving 24 COPD patients already treated with long-acting inhaled beta-agonist and long-acting anti-cholinergic bronchodilator therapy.ResultsAnalyzable data was available in 10 of 12 subjects in the treatment arm and 11 of 12 subjects in the control arm. Theophylline was associated with a 26.1% (95% confidence interval [CI]: −17.3–69.5) improvement in exercise duration compared to placebo. Four of 10 treated patients demonstrated an improvement in exercise duration exceeding the minimum clinically important difference of 33%, compared to 1 of 11 controls (P = 0.15). Furthermore, peak ventilation was reduced by 11.1%, (95% CI: 0.77–21.5) which may suggest improvements in gas exchange. There were no significant observed differences in resting lung function nor measures of dyspnea between the two treatment groups.ConclusionsOur study demonstrated a trend, but not a statistically significant improvement in exercise duration and a reduction in peak ventilation with theophylline. Based on the observed mean differences and standard deviations in this pilot study, a randomized controlled trial would require 45 subjects in each arm to detect a significant change in exercise duration.

Achieving symptom control in patients with moderate asthma.

Disease severity in asthma can be classified as mild, moderate or severe based upon the frequency of symptoms or the severity of airflow obstruction. This review will focus on the treatment of youths greater than 12 years of age and adults with moderate persistent asthma. Moderate asthmatics may have daily symptoms that cause some limitation with normal daily activities and require use of a rescue inhaled short-acting beta2-agonist inhaler or experience nocturnal awakenings secondary to asthma that occur more than once per week. Furthermore, spirometry may reveal airflow obstruction with a reduction in FEV1 to between 60% and 80% of predicted. Although inhaled corticosteroids (ICS) are the primary controller medication used to modify symptoms in moderate asthmatics, additional controller medications, such as inhaled long-acting beta2-agonists (LABA), leukotriene receptor antagonists (LTRA) or theophylline, are often needed to obtain optimal disease control. While the addition of an inhaled LABA to an ICS is very effective at improving disease control in moderate asthma, concerns have arisen over the safety of LABAs, in particular the risk of asthma-related death. Therefore, consideration may be given to initially adding a LTRA, rather than a LABA, to ICS when asthma symptoms are not adequately controlled by ICS alone. Furthermore, individualization of medication regimens, treatment of co-morbid conditions, and patient education are crucial to optimizing compliance with therapy, improving disease control, and reducing the risk of exacerbations. Lastly, the development of new asthma treatments, perhaps based upon personalized medicine, may revolutionize the future treatment of moderate asthma.

A cross-sectional observational study to investigate daily symptom variability, effects of symptom on morning activities and therapeutic expectations of patients and physicians in COPD-SUNRISE study

Chronic obstructive pulmonary disease (COPD) is a lung disease characterized with limitation of airflow that is not completely reversible, progressive deterioration of airways and systemic inflammation. This study has been planned to determine daily symptom variability of patients, expectations of patient and physicians from treatment and patient profiles. A total of 514 patients with COPD from 25 centers were included in this national, multicenter, cross-sectional observational study. Data regarding demographic features, concomitant diseases, history and treatment of COPD and expectations of patients and physicians were all obtained in a single visit. Mean [standard deviation (SD)] age of the patients was 64.1 (9.5) years; age range was 41-92 years, 50% of the patients were younger than 65 years and 91% were males. Educational level of the patients was at least primary school in 80.2%; and 54.3% (30.4%) of the patients had at least one concomitant disease, particularly a cardiovascular disease. Mean (SD) duration of having COPD was 5.4 (4.6) years. The majority of patients were at moderate (43.2%) and severe (35.0%) COPD stages and one or more exacerbations per year was determined in 71%. Inhaled beta-2 agonists (84.2%), inhaled steroids (76.3%) and inhaled long-acting anti-cholinergics (70.0%) were the most commonly used medications. Dyspnea (99.0%), sputum production (92.8%) and wheezing (90.5%) were the most common symptoms, and symptom variability for dyspnea (41.1%), sputum production (61.0%) and cough (53.5%) were seen the most in the morning hours (p< 0.001). Most commonly affected morning activity was climbing up/down the stairs (point of effect: 6.7), followed by wearing socks/shoes (point of effect: 4.3) and showering/bathing (point of effect: 4.2) by COPD. Major treatment expectations of patients were greater symptomatic relief (82.3%) and greater mobility (70.0%), faster symptomatic relief (61.1%) and improvement in morning activities (59.3%); while major treatment expectations of physicians included increased quality of life (100.0%) and decreased morbidity (96.0%). Quitting smoking was the most commonly recommended (88.3%) and implemented (67.9%) non-drug protective approach aimed at decreasing the frequency of exacerbations. Consequently, our results demonstrate that COPD is not a disease of only the elderly, is an important healthcare issue that often disrupt daily living of the patients due to inadequate disease awareness leading to overlooking of the symptoms by patient and physicians, and that a patient-centered approach based on the living standards, life expectancies and preferences of patients was crucial in patient management.