mucolytics were associated with a 21% reduction in yearly exacerbation rate when used for at
least 2 months, particularly in the winter months.
There was significant statistical heterogeneity in
the data. The meta-analysis was also confounded
by use of various agents that may have properties
in addition to mucolysis and inclusion of patients
with nonobstructive chronic bronchitis. There were
no significant untoward effects from the use of
Taken together, the role of mucolytics in the
treatment of stable COPD remains controversial.
GOLD guidelines suggest consideration of mucolytics as alternative agents in patients with high
symptom burden and high risk for exacerbations.
The past decade has ushered in a new era in
COPD pharmacotherapy wherein a shift in focus
from symptom treatment to affecting clinical out-
comes has occurred. Mega-trials have established
LAMA and LABA/ICS as efficacious drug catego-
ries in multiple outcome measures. The salutary
effects on outcome measures based on the litera-
ture discussed in this article are displayed by drug
category in Table 3. In this table, we label outcome
categories with a “yes” in the presence of evidence
from a RCT. We labeled outcome benefits that
were shown in post hoc analyses as “probable.”
Finally, the term “possible” was used when the evi-
dence came from retrospective analyses or in the
presence of strong trends that straddled statistical
significance (eg, mortality benefit from LABA/ICS
in the TORCH trial). With better understanding of
COPD pathogenesis, it is clear that a single agent
will not address the many facets of this devastating
disease. Adequately powered trials that incorpo-
rate combination therapies will provide guidance
and finesse the approach to the pharmacotherapy
of the patient with stable COPD.
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