This recommendation places high value on long-acting muscarinic antagonists reducing the risk of acute exacerbations of COPD, both moderate (required course of oral steroids, antibiotics, or both) and severe (required hospitalization), together with the comparative benefit of a long-acting muscarinic antagonist improving quality of life and lung function compared with placebo. Although pooled analyses show a reduction in COPD hospitalization with the use of a long-acting muscarinic antagonist compared with placebo, it does not reach statistical significance for all-cause hospitalization. This recommendation also acknowledges that there are no significant differences in serious adverse events or incidence of mortality between long-acting muscarinic antagonists and placebo in this patient group.