When should a second drug be added and does the combination of bagonist and anticholinergic really work better than higher doses of single drugs

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There is evidence that combined bronchodilator therapy (b-agonist with anti-cholingeric) produces greater bronchodilation than either drug given alone. This is true whether the agents are given in moderate dose (from hand-held inhalers) or in high doses (from small-volume nebulizers) [5,6].

If patients remains symptomatic despite treatment with a single bron-chodilator agent, it is reasonable to initiate a trial of combined therapy. However, combined therapy should be continued only if the patient reports a definite improvement from the addition of the second agent. A combination metered dose inhaler (MDI) containing b-agonist and anticholinergic agent may be convenient for such patients. For some patients, higher doses of a single agent may give better symptomatic relief. However, combined therapy may deliver similar symptomatic relief with less side-effects (e.g. tremor from high doses of b-agonist).

It is suggested that the prescriber should start either a b-agonist or an anticholinergic on an 'as required' basis. In some clinical studies, anticholinergics have produced greater overall bronchodilation but the b-agonist agents have a quicker onset of action. It is reasonable to allow patients to assess their response to each agent and select the medication that gives them optimal symptom relief.

If the patient needs to use their 'as required' treatment with increasing frequency, they should be advised to try taking the medication on a regular basis (e.g. qid) to see if this diminishes symptoms. If symptoms remain troublesome, the prescriber may increase the bronchodilator dose or consider adding a second agent or a long-acting b2-agonist (see next section).

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