Rapid Responses to:

PRACTICE: Graeme P Currie and Brian J Lipworth Pharmacological management—inhaled treatment BMJ 2006; 332: 1439-1441 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

The role of high dose steroids?

Janet M Corbett   (16 June 2006)

Figure showing TLC

Stefano De Luca, Ospedali Riuniti, 60020 Ancona, Italy   (16 June 2006)

Standards for ABCs due revision; recommendation at odds with evidence likely to harm.

Luis Gabriel Cuervo   (22 July 2006)

The role of high dose steroids? 16 June 2006
Janet M Corbett, PCT Chief Pharmacist Milton Keynes PCT, MK6 5NG Send response to journal: Re: The role of high dose steroids?	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
Figure showing TLC 16 June 2006
Stefano De Luca, Chest Physician SOD Pneumologia, Ospedali Riuniti, 60020 Ancona, Italy Send response to journal: Re: Figure showing TLC	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
Standards for ABCs due revision; recommendation at odds with evidence likely to harm. 22 July 2006
Luis Gabriel Cuervo, Unit Chief, Research Promotion & Development Pan American Health Organization, Washington DC Send response to journal: Re: 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.