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Glycopyrronium bromide is a new long-acting muscarinic antagonist to be used once-daily, which is approved as a bronchodilator for the symptomatic maintenance treatment of adult patients with chronic obstructive pulmonary disease (COPD). In the Glycopyrronium bromide in chronic Obstructive pulmonary disease airWays trials, treatment with inhaled glycopyrronium bromide at 50 μg once daily achieved a significantly better lung function than placebo, as measured by the trough forced expiratory volume in 1 s in patients with moderate-to-severe COPD. The lung function improvement was maintained for up to 52 weeks. Other improved indexes were dyspnea scores, health status, exacerbation rates and time of exercise endurance. Studies comparing the efficacy of glycopyrronium versus tiotropium bromide found substantial equivalence of the two drugs. Glycopyrronium was generally well tolerated. These data add inhaled glycopyrronium bromide to the treatment of patients with moderate to severe COPD as an effective once-daily LAMA.

Indacaterol was introduced as an agent of the new generation of very long acting beta2-agonists (VLABA) that provides a 24-hour activity of bronchodilation and allows a once-daily OD dosing. The first trial showed a significantly higher efficacy of indacaterol vs. placebo in patients with chronic obstructive pulmonary disease (COPD). The following trials were aimed at evaluating its performance compared with other bronchodilators. The results can be summarized in a comparable efficacy of indacaterol, mainly assessed by the increase in FEV1 value but also by quality of life and other patient- reported outcomes (PROs), compared with the OD antimuscarinic tiotropium bromide, and in a slightly higher efficacy compared with the LABA formoterol and salmeterol administered twice-daily. No problems of safety and tolerability were reported in the trials as well as in specific studies, every kind of adverse event, including cardiovascular effects, being similarly frequent with indacaterol and with placebo. Concerning the real-life management, in respect to LABA, the OD dosing makes indacaterol more convenient for COPD patients and is likely to positively influence the patient's adherence. Since adherence to medical treatment of chronic diseases, and particularly COPD is a crucial issue in medicine, such aspect should confer to indacaterol a valuable role in clinical practice. The recently approved combination of indacaterol with the antimuscarinic glycopyrronium [QVA149], based on the demonstration of positive effects on both lung function and PROs, is likely to be a further option for patients with severe COPD.