Table 5.

The principles of combining drugs used to treat chronic obstructive pulmonary disease (COPD). The general rule of drug therapy of COPD is that two drugs belonging to the same group or having similar mechanism of action should not be combined. The exception to this rule is the simultaneous use of short- and long-acting β₂-agonists that is allowed and often is meaningful

If there is a clinical indication to combine drugs from the following groups, there is no pharmacological reason to prevent the combination. To a single patient, only one compound or product can be selected from the following groups of drugs

Short-acting bronchodilators (‘reliever medication’)1

Short-acting β2-agonist (fenoterol, salbutamol, terbutaline)

Short-acting anticholinergic (ipratropium)2

Long-acting bronchodilators1

Long-acting β2-agonist (formoterol, indacaterol, olodaterol, salmeterol, vilanterol)

Long-acting anticholinergic (aclidinium, glycopyrronium, tiotropium, umeclidinium)2

Glucocorticoids

Inhaled glucocorticoids (beclomethasone, budesonide, fluticasone, mometasone, ciclesonide)

Oral medications

Phosphodiesterase 4 inhibitors (roflumilast)3

Theophylline3

¹The duration of action of the compound does not prevent the combination. For example, two long-acting bronchodilators can be combined as long as they have a different mechanism of action (i.e. tiotropium and indacaterol can be combined). Similarly, short-acting anticholinergic (ipratropium) can be combined with short-acting β₂-agonist (e.g. salbutamol). Instead, two different β₂-agonists with similar duration of action should not be combined (e.g. indacaterol should not be combined with formoterol or salmeterol). Use of a short-acting β₂-agonist as needed with a regular long-acting β₂-agonist is acceptable.

²Use of short-acting anticholinergic (ipratropium) with long-acting anticholinergic is not recommended.

³Phosphodiesterase 4 inhibitors and theophylline should not be combined because of the risk of adverse effects.