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LETTERS: Syed F Hussain Way forward is not obvious at asthma crossroads BMJ 2007; 335: 577 [Full text]

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The way forward is clear

Peter J Barnes   (26 September 2007)

The way forward is clear 26 September 2007
Peter J Barnes, Head of Respiratory Medicine Imperial College London, London SW3 6LY Send response to journal: Re: The way forward is clear	Unfortunately, Dr Hussein does not seem to recognise that the “three matching studies from the rival manufacturer showing the opposite effects” did not investigate single inhaler therapy. Two of the publications are from the same study called CONCEPT (Seretide vs Symbicort adjustable maintenance dosing), where the majority of patients used 1 inhalation of budesonide/formoterol (160/4.5 µg) as maintenance and a short-acting beta2- agonist, rather than the combination inhaler, as rescue therapy. This was compared to fluticasone/salmeterol 50/250 µg twice daily. The third publication is the EXCEL study, comparing fixed dose budesonide/formoterol vs fixed fluticasone/salmeterol, which uses 1% of the exacerbation data to claim an advantage for fluticasone/salmeterol. There were no differences between the treatments for any outcomes when looking at the whole study period. My paper summarised the data for single inhaler therapy with budesonide/formoterol studies in over 14,000 patients, and described consistent efficacy advantages vs high dose inhaled corticosteroid or combination inhalers with short-acting beta2-agonists as rescue therapy. Competing interests: PB has received funding for lectures and research from GlaxoSmithKline, AstraZeneca, Novartis, Pfizer and Boehringer Ingelheim.