The subject of this review is alpha-1-antitrypsin deficiency (A1AD), which is a rare hereditary disease with great impact in adults, especially smokers, quality of life and longevity. Early diagnosis is crucial for treatment outcome. The primary care physician should refer patients younger than 50-years-old with COPD or emphysema, familiar accumulation of A1AD or liver cirrhosis of unknown cause. Most important treatment is smoking cessation, pulmonary rehabilitation and inhaled medication according to current guidelines. Substitution treatment with alpha-1-antitrypsin is now an option after its approval by the Danish medical council in January 2020.