Comparison of inhaled long-acting β-agonist and anticholinergic effectiveness in older patients with chronic obstructive pulmonary disease: a cohort study

Ann Intern Med. 2011 May 3;154(9):583-92. doi: 10.7326/0003-4819-154-9-201105030-00003.


Background: Chronic obstructive pulmonary disease (COPD), a largely preventable and manageable respiratory condition, affects an estimated 12% to 20% of adults. Long-acting inhaled β-agonists and anticholinergics have both been shown to improve COPD outcomes and are recommended for moderate to severe disease; however, little is known about their comparative effectiveness.

Objective: To compare survival in older patients with COPD who initially receive inhaled long-acting β-agonists with that of patients who receive anticholinergics.

Design: Population-based, retrospective cohort study.

Setting: Ontario, Canada.

Patients: Patients aged 66 years or older (who carry the largest burden of COPD and for whom data were available) who met a validated case definition of COPD on the basis of health administrative data and were newly prescribed an inhaled long-acting β-agonist or a long-acting anticholinergic (but not both) between 2003 and 2007. Patients were followed for up to 5.5 years.

Measurements: The primary outcome was all-cause mortality.

Results: A total of 46 403 patients with COPD (mean age, 77 years; 49% women) were included. Overall mortality was 38.2%. Mortality was higher in patients initially prescribed a long-acting anticholinergic than in those initially prescribed a long-acting inhaled β-agonist (adjusted hazard ratio, 1.14 [95% CI, 1.09 to 1.19]). Rates of hospitalizations and emergency department visits were also higher in those initially prescribed a long-acting anticholinergic.

Limitation: Patients were classified as having COPD on the basis of health administrative records, which did not contain information about lung function.

Conclusion: Older adults initially prescribed long-acting inhaled β-agonists for the management of moderate COPD seem to have lower mortality than those initially prescribed long-acting anticholinergics. Further research is needed to confirm these findings in younger patients and in a randomized, controlled trial.

Primary funding source: Government of Ontario, Canada.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administration, Inhalation
  • Adrenergic beta-Agonists / administration & dosage
  • Adrenergic beta-Agonists / therapeutic use*
  • Aged
  • Bronchodilator Agents / administration & dosage
  • Bronchodilator Agents / therapeutic use*
  • Cause of Death
  • Cholinergic Antagonists / administration & dosage
  • Cholinergic Antagonists / therapeutic use*
  • Female
  • Humans
  • Male
  • Ontario / epidemiology
  • Propensity Score
  • Proportional Hazards Models
  • Pulmonary Disease, Chronic Obstructive / drug therapy*
  • Pulmonary Disease, Chronic Obstructive / mortality
  • Retrospective Studies
  • Sensitivity and Specificity
  • Treatment Outcome


  • Adrenergic beta-Agonists
  • Bronchodilator Agents
  • Cholinergic Antagonists