Maintenance pharmacotherapy of mild and moderate COPD: what is the evidence?

Chronic obstructive pulmonary disease (COPD) affects more than 24 million individuals in the United States, although at least half of the cases are not diagnosed. Proactive diagnosis and limitation of risk exposure from smoking or pollutants are important to improve prognosis. Pharmacologic treatments are prescribed according to COPD stage and symptoms. Mild COPD is symptomatically treated 'as needed' with short-acting bronchodilators; major guidelines recommend starting maintenance treatment at the moderate COPD stage with long-acting bronchodilators; inhaled corticosteroids may be added for patients with more severe disease and frequent exacerbations. Maintenance therapy preserves 24-h airway patency, reduces exacerbations, and improves activity tolerance and health-related quality of life. Recent post-hoc analyses of large clinical trials that contain subgroups of patients with less severe COPD suggest that, similar to those with advanced disease, patients with moderate disease benefit from long-term maintenance therapies. Studies suggest symptomatic mild patients may also benefit. This concept needs to be prospectively tested in studies specific to these COPD disease stages. Proactive identification and pharmacologic intervention in early COPD has the potential to alter clinical outcomes throughout the disease course.