The treatment traditionally recommended for patients with chronic obstructive pulmonary disease (COPD) has been based on drugs that were initially developed for the treatment of bronchial asthma. This anomalous situation resulted from two causes: on one hand, the investigation of the physiopathology and pharmacology of COPD was very scarce and, on the other hand, there was the erroneous impression that all obstructive bronchial diseases followed the same pathogenic mechanisms. Similarly, the Global Initiative for Obstructive Lung Disease (GOLD) guidelines adopted a stepwise approach for pharmacological treatment of COPD, which was exactly the same approach as that in the Global Initiative for Asthma (GINA) guidelines. Fortunately, in recent years new drugs have been developed according to the specific pathogenic mechanisms of COPD.
It needs to be recognized that COPD is a complex disease, and many different phenotypes are included under the umbrella of the acronym COPD. One of these phenotypes is the chronic expectorator, which usually presents an increased risk of exacerbations and faster decline in lung function. A novel oral anti-inflammatory specific for COPD, roflumilast, has demonstrated efficacy in improving lung function and reducing exacerbations in patients with severe COPD and chronic expectoration, even in addition to long-acting bronchodilators. These results provide a different and promising approach to the management of patients with severe COPD.
The future trend in the treatment of COPD will be, undoubtedly, to use drugs once daily to ensure maximum compliance. The possibility of long-term oral once-daily administration offers a new perspective on patients already treated with multiple inhalation devices. It should be taken into account, however, that most patients are elderly, taking multiple medications, and treatment is indefinite in length. There is no longer one treatment for COPD; thus, similar to what occurs with other chronic diseases such as hypertension or diabetes, different therapeutic options should be individualized based on the characteristics of each patient.