CHEST Guidelines--strong-COUNTERPOINT---strong--Should-LAMA-LABA-Co

-strong-COUNTERPOINT---strong--Should-LAMA-LABA-Co

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In their discussion, Dr. Miriam Barrecheguren and Dr. Marc Miravitlles argue against using LAMA/LABA combination therapy as an initial maintenance treatment for the majority of COPD patients. According to the recent Global Initiative for Obstructive Lung Disease (GOLD) report, this dual therapy is initially recommended only for group D patients, who suffer frequent exacerbations and exhibit a high level of symptoms, which constitutes only about one-third of COPD patients treated in respiratory clinics. Single long-acting bronchodilators (LABD) are suggested for the majority of patients due to several reasons.<br /><br />Firstly, exacerbations in a subset of patients with T-cell type 2–dominant inflammation (asthma-COPD overlap) should be addressed with a LABA and inhaled corticosteroid combination instead. For many patients with milder COPD symptoms, the improvement in lung function outcomes with combined LAMA/LABA therapy is marginal and not always clinically relevant. Furthermore, trials predominantly involved severe COPD patients, not reflecting the larger population with milder symptoms seen in primary care, where single bronchodilators have shown significant benefit.<br /><br />Improvements in exercise capacity and quality of life metrics with dual bronchodilation over monotherapy have been inconsistent or minimal. Safety concerns over dual therapy include increased risks of cardiovascular events, especially since trials often exclude patients with pre-existing cardiovascular conditions—common comorbidities in COPD sufferers.<br /><br />Despite these arguments, LAMA/LABA should remain the go-to therapy for patients with severe COPD or more pronounced symptoms. In contrast, those with mild to moderate disease might not notice significant advantages from dual bronchodilation and might better start with single bronchodilators, reserving dual therapy for cases of insufficient symptom relief. Cardiovascular safety in broader patient populations remains a concern with dual bronchodilator use.

Keywords

COPD

LAMA/LABA

bronchodilators

GOLD report

asthma-COPD overlap

single therapy

dual therapy

cardiovascular risks

exercise capacity

quality of life