Tiotropium compared with ipratropium for patients with moderate to severe chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major respiratory illness affecting over 700, 000 Canadians and is preventable and treatable, but not curable. It is the fourth leading cause of death in Canada, with mortality rates increasing over the past fifteen years, especially in women. According to the Canadian Institute for Health Information, COPD accounts for the highest rate of hospital admission and readmission among major chronic diseases in Canada. Exacerbations are the principal cause of hospitalizations. Management should be patient focused, consisting of a combination of risk factor reduction, pharmacotherapy, education, pulmonary rehabilitation, and exercise programs to improve symptoms and activity levels, reduce exacerbations, and improve or maintain overall quality of life. Smoking cessation is the most effective intervention that reduces the risk of developing COPD and the only intervention that has been shown to slow the rate of lung function decline. Pharmacotherapy is introduced in a step wise approach. Bronchodilators are the cornerstone of COPD therapy and include inhaled short and long acting beta-2 agonists and short and long acting anticholinergics. They act by decreasing airway smooth muscle tone, which increases expiratory flow rates and reduces hyperinflation with a subsequent reduction in dyspnea, improved exercise tolerance, and health status. The two anticholinergics available in Canada are ipratropium bromide, a short acting agent available as nebules and metered dose inhaler dosed up to four times a day and tiotropium bromide, a long acting agent available as capsules that are inhaled via a Handihaler device with once daily dosing. Ipratropium and tiotropium are recommended separately for the treatment of COPD. A Rapid Response regarding this topic was produced by CADTH in 2009, with the conclusion that, "spirometery measures typically did not differ between treatments over this time period. Further, symptoms of COPD did not differ between tiotropium and ipratropium and other