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Bronchodilators or combination of long acting beta 2 adrenergic and inhaled steroids: another competition in the future?!

If we are looking into the real problems of chronic obstructive pulmonary disease (COPD) we can find out many current problems unsolved at this moment: it's a prevalent major medical problem, underdiagnosed, unrecognized, untreated. The current therapies also have their own problems. Monotherapy with bronchodilators is sometimes not sufficient, combinations of different classes of bronchodilators sometimes have not well defined indications and the combination of bronchodilators and inhaled corticosteroids (ICS) is more criticized every day. If we are thinking also that the opinion leaders are speaking more and more about personalized treatment, the puzzle of diagnosis and therapy of COPD is becoming more difficult. We know that regular therapy with long‑acting bronchodilators (LABA: long-acting beta-adrenergic agonists; LAMA: long-acting antimuscarinic agents) improves lung function, dyspnoea and quality of life in symptomatic patients with spirometric evidence of airflow obstruction(1,2). As a consequence of different studies concerning long-acting bronchodilators, was added the effect on reducing the rate of exacerbations, probably due to a reduction in pulmonary hyperinflation and a resetting of lung function dynamics(3). In the same time, even if updated GOLD is very restrictive for stage C and D patients, the combination of LABA and ICS was overprescribed(4,5) in patients with FEV1 > 50% predicted and history of less than 2 exacerbations per year, despite the well known significant adverse effects(6), particularly regarding an increased risk of pneumonia.