Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality and morbidity worldwide. In addition to generating high healthcare costs, COPD imposes a significant burden in terms of disability and impaired quality of life. Unlike many leading causes of death and disability, COPD is projected to increase in many regions of the world as the frequency of smoking is rising and the population is aging. The pharmacological treatment of COPD includes bronchodilators to relax smooth muscle, such as β2-agonists (salbutamol, terbutaline, and fenoterol, short-acting β2-agonists as well as salmeterol, formoterol, and indacaterol, and long-acting β2-agonists) and anticholinergics, such as ipratropium, oxitropium (short-acting anticholinergic), and tiotropium (long-acting anticholinergic). Although airway inflammation in COPD poorly responds to steroids, several inhaled corticosteroids (fluticasone, budesonide, and beclomethasone) are in use in combination with long-acting β2-agonists. Other medications include theophylline (both a bronchodilator and a phosphodiesterase inhibitor) and the phosphodiesterase-4 antagonists, such as roflumilast. Finally, a number of novel long-acting anticholinergics and β2-agonists with once- or twice-daily profiles are in development and clinical testing. 1. Introduction Chronic obstructive pulmonary disease (COPD) is a respiratory disease characterized by chronic airway inflammation, a decline in lung function over time, and progressive impairment in quality of life. The disease has relatively high prevalence rates worldwide (5–13%) [1, 2] and is mainly caused not only by the inhalation of noxious substances, predominantly cigarette smoking in the Western world, but also by indoor air pollution, particularly in the developing countries. COPD is associated with high mortality and morbidity rates and a high economic and social burden, mainly due to the requirement for substantial and ongoing medical support [3, 4]. COPD is the fourth leading cause of death worldwide and is expected to be the third leading cause by 2030 [5]. It is generally believed that despite the availability of both national and international guidelines, COPD remains substantially underdiagnosed and undertreated and is rarely regarded as a health issue of top priority. For many years, smoking cessation has been known to be the single effective intervention for reducing the risk of developing COPD and slowing its progression down [6]. However, recent data from long-term trials have shown that initiating maintenance pharmacological treatment at
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