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LETTERS: Peter D Burrill Drug management of COPD BMJ 2007; 334: 864-a [Full text]

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Correction to Drug management of COPD

Peter D Burrill   (30 April 2007)

Correction to Drug management of COPD 30 April 2007
Peter D Burrill, Specialist Pharmaceutical Adviser for Public Health Derbyshire County PCT, Chesterfield, S41 7PF Send response to journal: Re: Correction to Drug management of COPD	Unfortunately an error occured in the editing of my letter, which changed the emphasis and meaning somewhat. Here is a corrected version. In the second step of prescribing for long term management of chronic obstructive pulmonary disease, McIvor and Little recommend the addition of a long acting beta 2 agonist (LABA) to regular short or long acting anticholinergic inhalers with a short acting beta 2 agonist as needed.1 Is this the best approach? The National Institute for Health and Clinical Excellence (NICE) also recommends adding a LABA in its COPD guideline (No12, 2004).2 At that time there was no evidence to show whether this was a useful combination, but now evidence shows the addition of LABA to tiotropium has no additional benefit over tiotropium alone,3 so this is not really a suitable option. The authors' next step is to add an inhaled corticosteroid or a combination of inhaled corticosteroid and LABA as a single inhaler. If an inhaled corticosteroid is to be used in COPD then it should be in line with the NICE guideline. Unfortunately, evidence that a combination inhaler such as Seretide (fluticasone propionate and salmeterol) produces clinically important benefit over and above the separate components is lacking. For example, the recent TORCH study showed no benefit of Seretide over salmeterol or fluticasone alone at reducing severe exacerbations.4 If a patient on regular tiotropium and as needed short acting beta 2 agonist requires additional drug treatment then I suggest that the two options are to add an inhaled corticosteroid (as per NICE guidance) or add an oral mucolytic. To assess the effectiveness of drug therapy I suggest using the five questions (similar to using three questions in asthma) as recommended by Jones.5 1. McIvor A, Little P. Chronic obstructive pulmonary disease. BMJ 2007;334:798. (14 April.) 2. NICE. Chronic obstructive pulmonary disease. London: NICE, 2004. http://guidance.nice.org.uk/CG12http://guidance.nice.org.uk/CG12 3. Aaron SD, Vandemheen KL, Fergusson D, Maltais F, Bourbeau J, Goldstein R, et al. Tiotropium in combination with placebo, salmeterol, or fluticasone-salmeterol for treatment of chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med 2007;146:545-55. 4. Calverley PM, Anderson JA, Celli B, Ferguson GT, Jenkins C, Jones PW, et al. Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. N Engl J Med 2007; 356: 775-89. 5. Jones PW. Health status measurement in chronic obstructive pulmonary disease. Thorax 2001; 56: 880-7. Competing interests: None declared