I thank Dr Crouch et al for their comments and their reminders of the current standards of care for COPD. Scheduled dosing of ipratropium is to be used as initial therapy for patients with COPD and a selective β-agonist is taken for symptomatic relief, or scheduled when a patient requires continous treatment. It is for the patients who regularly take both ipratropium and albuterol that combination therapy might be both less expensive and more convenient. The primary indication of combination therapy is to simplify the inhaler regimen and improve medication adherence of patients requiring scheduled dosing of ipratropium and albuterol. A combination inhaler might not be suited for those patients who require monitoring of drug use as an index of their severity, although as-needed drug use can also be monitored during routine therapy. There are several studies needed to examine the roles of different medications in COPD. A study to compare scheduled-dosing albuterol with symptomatic-dosing albuterol treatment in patients taking ipratropium would help to define the relative efficacy of these 2 albuterol treatment strategies.
Campbell SC. Use of the Combination Product Ipratropium and Albuterol in Chronic Obstructive Pulmonary Disease. Arch Intern Med. 1999;159(13):1499. doi: