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Am Fam Physician. 1999;59(11):3195-3196

Chronic obstructive pulmonary disease (COPD) is characterized by air flow obstructions that result from bronchitis or emphysema. Exacerbations of the disease are common, resulting in additional costs and increased utilization of health care resources. Therapy with bronchodilators, such as ipratropium and albuterol, can often reverse the airway hyper-reactivity associated with COPD. The combination of these two agents has been shown to provide greater bronchodilation than each agent alone. However, little is known about the effect of this combination on costs and utilization of health care resources. Friedman and associates conducted a post-hoc review of two double-blinded, randomized prospective trials on the safety and efficacy of these two agents when used alone or in combination to evaluate the pharmacoeconomic effects of each regimen.

Both studies included patients with an established diagnosis of COPD, characterized by stable, moderately severe air flow obstruction and use of two or more pulmonary agents to control their symptoms. Physical examination, laboratory studies and electrocardiography (ECG) were performed at entry and at the end of the study. Following a two-week baseline, patients were randomized to receive ipratropium, albuterol, or a combination of the two agents. Pulmonary function tests were performed on days 1, 29, 57 and 85 in all groups at 15-minute intervals for the first hour, then hourly for eight hours. Data on utilization of health care resources, including the number and severity of exacerbations, the number and length of hospital stays resulting from exacerbations, and the number of patient days of increased doses or additional medications needed were collected as well.

The combination of ipratropium and albuterol significantly improved peak forced expiratory volume when compared with each agent independently. Patients taking albuterol alone had more exacerbations of COPD, more hospitalization days and increased use of additional medication than patients treated with ipratropium alone or ipratropium in combination with albuterol. As a result, the total cost of care was higher in this group, despite the fact that albuterol costs less than the other agents. Patients who received ipratropium alone or in combination with albuterol experienced fewer exacerbations, had fewer hospital stays and took fewer additional medications.

The authors conclude that the combination regimen should be considered early in the management of moderate or severe COPD, as it provides superior bronchodilation and is associated with fewer exacerbations than albuterol or ipratropium alone. Fewer exacerbations improves the quality of life and significantly reduces the cost of health care for these patients.

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Copyright © 1999 by the American Academy of Family Physicians.

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