| Anticholinergics (inhaled) |
| Ipratropium (Atrovent) | 2 or 3 puffs three or four times daily | $77 (for 14 g; 200 inhalations) | Anaphylaxis, angioedema, bronchospasm (paradoxical), glaucoma (narrow-angle), hypersensitivity reaction, laryngospasm | COPD exacerbation, cough, dizziness, dry mouth, GI upset, headache, nausea, nervousness, oral irritation, rash, urticaria | Improves symptoms and quality of life and decreases exacerbations, hospitalizations, and deaths6,7 |
| Tiotropium (Spiriva) | 1 cap daily | 140 | Angioedema, bronchospasm (paradoxical), glaucoma, hypersensitivity reaction | Abdominal pain, blurred vision, candidiasis, chest pain, constipation, dry mouth, dyspepsia, edema, epistaxis, infection, myalgia, pharyngitis, rash, rhinitis, tachycardia, URTI symptoms, urinary hesitancy or retention, UTI, vomiting | Improves quality of life and sleep and decreases rescue inhaler use and office visits8–10 |
| Higher cost |
| Beta2 agonists (inhaled) |
| Albuterol (Ventolin HFA) | 2 to 4 puffs every 6 hours as needed | 36 (for 18 g; around 200 inhalations) | Angina, angioedema, arrhythmias, bronchospasm (paradoxical), hypertension, hypokalemia, QT-interval prolongation, seizures, urticaria | Bad taste in the mouth, cough, throat irritation, tremor, URTI symptoms | Improves breathlessness but not other patient-oriented outcomes11 |
| Salmeterol (Serevent) | 1 inhalation every 12 hours | 131 | Anaphylaxis, angioedema, arrhythmias, asthma exacerbation, bronchospasm (paradoxical), death (asthma-related), hypertension, laryngospasm | Bronchitis, headache, nasal congestion, nervousness, palpitations, pharyngitis, rash, rhinitis, tachycardia, throat irritation, tracheitis, tremor, urticaria | Does not improve breathlessness but may decrease exacerbations (single study)12 |
| Corticosteroids (inhaled) |
| Fluticasone (Flovent HFA; 44 to 220 mcg per puff) | 88 to 440 mcg two times daily | 90 (for 10.6 g; around 120 inhalations) | Adrenal suppression, anaphylactoid reactions, angioedema, behavioral disturbances (children), bronchospasm, cataracts, Churg-Strauss syndrome, Cushingoid features, eosinophilia, glaucoma, growth suppression (children), hyperglycemia, osteoporosis, vasculitis | Candidiasis (oral), cough, dysphonia, headache, hoarseness, pharyngitis, sinusitis, throat irritation, URTI | Decrease exacerbations in patients with moderate to severe disease13 |
| Budesonide (Pulmicort; 90 to 180 mcg per puff) | 180 to 360 mcg two times daily | 177 (200 inhalations) | Maintain lowest effective dose |
| Triamcinolone (Azmacort;100 mcg per puff) | 2 puffs three or four times daily | 134 (for 20 g; around 240 inhalations) |
| Combinations |
| Inhaled anticholinergic/short-agonist (albuterol/acting beta2 ipratropium [Combivent]) | 1 or 2 puffs four times daily as needed | 100 (for 14.7 g; around 200 inhalations) | Anaphylaxis, angioedema, arrhythmias, bronchospasm (paradoxical), glaucoma (narrow-angle) | Bronchitis, cough, dyspnea, headache, nausea, pain, URTI | Use in patients requiring more than one bronchodilator |
| Inhaled corticosteroid/long-acting agonist (fluticasone/beta2 salmeterol inhaled [Advair Diskus]: 100/50, 250/50, or 500/50 mcg per puff) | 1 inhalation twice daily | 210 | Adrenal suppression, angioedema, arrhythmia (ventricular), asthma exacerbation, bronchospasm (paradoxical), cataracts, Churg-Strauss syndrome, cushingoid features, death (asthma-related), glaucoma, growth suppression (children), hypokalemia (severe), laryngospasm | Bronchitis, candidiasis (oral), cough, dermatitis, diarrhea, dizziness, dyspepsia, dysphonia, headache, hoarseness, hypokalemia, nausea or vomiting, palpitations, pharyngitis, sinusitis, taste changes, throat irritation, tremor, URI | Improves lung function and quality of life and decreases exacerbations in patients with moderate to severe disease14 |
| Mucolytics |
| n-acetylcysteine (Mucomyst‡) | 600 mg orally two times daily | 328 (4 mL 20% solution) | Anaphylaxis, bronchospasm | Bronchospasm, nausea, rash, rhinorrhea, stomatitis, unpleasant odor during administration, urticaria, vomiting | Small decrease in exacerbations15 |