Pharmacological management—inhaled treatment
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7555.1439 (Published 15 June 2006) Cite this as: BMJ 2006;332:1439
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Figure showing total lung capacity and tidal volume is misleading
(for me) for
one aspect.
TLC height is changing in the last three bars (patients with COPD) and it
occurs
during exercise and/or after drug. To my knowledge TLC is a stable value
and
it is not modified by exercise and/or drug.
Figures are important communication tool and they must not be misleading
Competing interests:
None declared
Competing interests: No competing interests
The statement by Currie and Lipworth that "The dose of inhaled
corticosteroid required to achieve maximal beneficial effect with minimal
adverse effect (optimum therapeutic ratio) is uncertain, and more data are
needed. As a consequence, consider prescribing regular, high dose, inhaled
corticosteroids in patients with an FEV1 < 50% of predicted and who
experience frequent exacerbations (> 2 a year" puzzles me. It seems an
enormous leap in faith to say that the dose of inhaled steroids is
uncertain and then to promote the use of a high dose.
We are already aware that inhaled corticosteroids demonstrate a
relatively flat dose response curve (Masoli et al Thorax 2004;59:16-20,
and Holt et al BMJ 2001; 323: 253-256). Furthermore,Sinn and Mann, Eur
Resp J 2003; 21: 260-266 showed little difference in mortality between
medium and high dose steroids in COPD.
In my role as a Pharmaceutical Adviser, I have just written a
briefing on inhaled corticosteoids, including a case study of a tragic
death due to high dose steroids. It is unhelpful to see high dose steroids
being promoted without robust evidence to support it.
Competing interests:
None declared
Competing interests: No competing interests
Standards for ABCs due revision; recommendation at odds with evidence likely to harm.
On June 17 2006 the BMJ published a recommendation on treatments for
asthma (http://bmj.bmjjournals.com/cgi/content/full/332/7555/1439). A week
later it published a news article describing potential risks associated
with the use of long acting beta-
agonists (http://bmj.bmjjournals.com/cgi/content/full/332/7556/1467-
a). The 17 th of June recommendations are part of the ABC of Chronic
Obstructive Pulmonary Disease entitled Pharmacological management-inhaled
treatment. It has no methods section, no explicit literature review, and
it is unclear how the authors concluded that treatment would result in
benefits because the article resorted to physio-pathological theories
instead of using available clinical studies. These recommendations will
soon appear in a book, according to the article. The authors disclosed a
long list of conflicting interests and strong links to companies producing
the recommended therapies.
The BMJ News article by Pat Hagan reports a meta-analysis published
the 5 of June 2006 in Annals of Internal Medicine
, suggesting that
long acting beta-agonists increase mortality and morbidity, and
importantly so. The review followed an explicit scientific methodology,
described its limitations, and focused on sound clinical outcomes. No
competing interests were declared by the authors.
The BMJ has advocated for patient safety through its publications and
by supporting other activities. It has also demonstrated leadership in the
evidence-based approach to health care. To remain consistent with this
lines of action, it needs to review the production processes for its ABC
series and the recommendations these deliver. The BMJ has a duty to ensure
that the recommendations in the ABC of Chronic Obstructive Pulmonary
Disease are not going to put people in harms way.
A review on
the policies behind the production, publication, and marketing of ABCs by
the BMJ would be welcomed by readers of the BMJ interested in staying
abreast of current knowledge on health care.
Luis Gabriel Cuervo is a Family Physician a Clinical Epidemiologist,
and BMA Member. His comments do not necessarily reflect the position of
his employer or former employers.
Competing interests:
LGC worked with BMJ Knowledge, a division of the BMJ Publishing Group, between 2000 and August 2005.
Competing interests: No competing interests