Erdosteine is a drug approved for the treatment of acute and chronic pulmonary diseases, originally developed as a mucolytic
agent. It belongs to the thiol-based family of drugs that are known to also possess potentially important antioxidant and
anti-inflammatory properties, and exhibit antibacterial activity against a variety of medically important bacterial species.
Erdosteine is a prodrug that is metabolized to the ring-opening compound metabolite M1 (MET 1), which has mucolytic properties.
Experimental studies have documented that erdosteine prevents or reduces lung tissue damage induced by oxidative
stress and, in particular, that Met 1 also regulates reactive oxygen species production. The RESTORE study, which has been
the only trial that investigated the effects of a thiol-based drug in chronic obstructive pulmonary disease (COPD) frequent
exacerbators, documented that erdosteine significantly reduces the risk of acute exacerbations of COPD (AECOPDs), shortens
their course, and also decreases the risk of hospitalization from COPD. The preventive action of erdosteine on AECOPDs was
not affected by the presence or absence of inhaled corticosteroids (ICSs) or blood eosinophil count. These findings clearly
contrast with the Global Initiative for Chronic Obstructive Lung Disease strategy’s approach to use erdosteine only in those
COPD patients not treated simultaneously with an ICS. Furthermore, they support the possibility of using erdosteine in a
step-down approach that in COPD is characterized by the withdrawal of the ICS.

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