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PAPERS: Felix S F Ram, John Wright, David Brocklebank, and John E S White Systematic review of clinical effectiveness of pressurised metered dose inhalers versus other hand held inhaler devices for delivering 2 agonists bronchodilators in asthma BMJ 2001; 323: 901 [Abstract] [Full text]

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Asthma and clinical effectiviness of different inhaler devices

E Dompeling, Dompeling E   (1 December 2001)

Bronchodilators, Corticosteroids and leukotriene antagonists in Indian Asthmatics

S K Agarwal   (27 March 2002)

Asthma and clinical effectiviness of different inhaler devices 1 December 2001
E Dompeling, Dept of Paediatric Pulmonology University Hospital of Maastricht, PO Box 5800, 6202 AZ Maastricht, Netherlands, Dompeling E Send response to journal: Re: Asthma and clinical effectiviness of different inhaler devices	Editor of the BMJ BMA house Tavistock Square London WC1J 9JR UK Dear Sir, Recently, 2 outstanding systematic reviews on the clinical effectiveness of pressured metered dose inhalers (pMDI) versus other hand held devices for delivery of inhaled medication appeared in the journal (1,2). By systematically evaluating randomised controlled trials on this topic, the conclusion of these papers was almost the same for both inhaled bronchodilators and inhaled corticosteroids: no evidence was found that alternative inhaler devices (dry powder inhalers, breath actuated pressurised metered dose inhalers) are more effective than the pMDI for the delivery of inhaled medication. Therefore, pMDI remains the most cost effective first-line device for administrating inhaled therapy (1,2). Studies in both children and adults were analysed. Although we in general subscribe this conclusion, we want to draw attention on a confusing passage which is prone for drawing wrong conclusions from these reviews. The authors discuss pressured metered dose inhalers with or without spacer devices compared with alternative inhaled devices (page 900, line 16 from above and page 902, line 7 from below). This is a somewhat unlucky phrasing because the reader may conclude that pMDI with or without a spacer does not make any difference in clinical effectiveness. In at least one patient category this is certainly not true. It has been repeatedly shown that pMDI in children under the age of 8 are only effective in combination with a spacer device (3), which is also recommended in the current guidelines (4). The use of a pMDI alone in young children will give almost no lung deposition and therefore is useless. In our experience, it still happens that physicians or parents use this wrong way of administrating inhaled medication to children. Moreover, also elderly patients with hand-lung co-ordination problems are likely to benefit from the easiness of the combination of a pMDI with a spacer device (5). We think that these aspects are an important addition to these excellent reviews. 1. Brocklebank D, Wright J, Cates Christopher. Systematic review of clinical effectiveness of pressurised metered dose inhalers versus other hand held inhaler devices for delivering corticosteroids in asthma. BMJ 2001;322:896-900. 2. Ram Felix SF, Wright J, Brocklebank D, White John ES. Systematic review of clinical effectiveness of pressurised metered dose inhalers versus other hand held inhaler devices for delivering beta-2 agonist bronchodilators in asthma. BMJ 2001;323:901-905. 3. Bisgaard H. Delivery of inhaled medication to children. J Asthma 1997;34:443-467. 4. Chernick V, Boat TF, Kendig Jr EL. Kendig’s disorders of the respiratory tract in children, 6th edition, page 718-719, WB Saunders Company, London, 1998. 5. Ikeda A, Nishimura K, Izumi T. Pharmacological treatment in acute exacerbations of COPD (review). drugs Aging 1998;12:129-137. Edward Dompeling, MD, PhD1,2 Han Hendriks, MD2 Quirijn Jöbsis, MD, PhD2 Professor Raymond Donckerwolcke1 1 Dept. of Paediatrics and 2 Dept. of Paediatric Pulmonology, University Hospital of Maastricht, PO Box 5800, 6202 AZ Maastricht, Netherlands Correspondence: E. Dompeling (phone ++31-43-3875284, fax ++31-43- 3875246, e-mail: edom@skin.azm.nl)
Bronchodilators, Corticosteroids and leukotriene antagonists in Indian Asthmatics 27 March 2002
S K Agarwal, Head, Department of Chest Diseases, Institute of Medical Sciences, BHU, Varanasi,India Send response to journal: Re: Bronchodilators, Corticosteroids and leukotriene antagonists in Indian Asthmatics	Inhalation of bronchodilators and corticosteroids is the mainstay of treatment for patients with asthma. Many inhaler devices and drug combinations are now available in India, and competing promotional claims confuse both prescribers and patients. The cost of the drug used in specific devices differs greatly. International guidelines are inconsistent in their recommendations for prescribing inhaler devices in different age groups. It’s strange that there are no National guidelines for the management of asthma by Indian doctors for Indian patients thus treating physicians are as confused as patients. Thus more and pharmaceutical companies are coming out with inhalers and other devices; some of them without any scientific rationale. Recently, pharmaceutical industries have launched leukotriene- modifying drugs without any definite clinical trial in Indian patients and after reading some conflicting reports about the efficacy of these drugs the Indian doctors have become more confused. I strongly feel that Indian patients should have been included in the multicentre, multinational, double-blind clinical trial to know the efficacy of new antiasthmatic drug. Competing Interests: None