Objective: Patterns of medication use and adherence towards the end of life in chronic obstructive pulmonary disease (COPD) patients is poorly understood. This study aimed to examine medication adherence and persistence among COPD patients during their last year of life. Methods: From national VA databases, we identified newly diagnosed COPD patients between 1999 and 2003 who died during follow-up. We examined use of inhaled corticosteroids (ICS), long-acting â2 agonists (LABA), methylxanthines (MTX), and anticholinergics (AC), alone and in combination. Medication possession ratios (MPR) were compared between regimens by quarterly periods using General Estimating Equations (GEE). Medication persistence, calculated as the time from index date to an occurrence of at least 30 days between refills, was examined in monotherapy users with Kaplan-Meier survival analysis and extended Cox proportional hazard models. Results: Among 5913 patients who received medications and died during follow-up, overall mean (SD) MPR was 0.44 (0.32) during the last year of life, being highest among MTX users (mean MPR=0.52, SD=0.32). ICS-only users had lower MPRs than the AC reference group (â=-0.0311, p=0.03). A positive linear trend in MPR was observed across quarterly periods in AC users (â=0.014, p<0.0001), and was highest for MTX users (â=0.11, p<0.0001). MPRs for MTX or multiple medication users were significantly higher than the reference group. Of 3436 on monotherapy only, approximately 40% discontinued medication within 30 days and 70% discontinued within 90 days. Days to discontinuation ranged from mean (SD) of 79 (91) for LABA to 126 (129) for MTX. MTX users were less likely to discontinue (HR = 0.714, p=0.012) than reference (AC) group. African-Americans had a higher risk of discontinuation than Caucasians. Conclusion: More severe COPD patients, e.g. methylxanthine and multiple medications users, were more adherent and/or persistent with their regimens. Future research needs to link compliance to outcomes towards end-of-life.