I read with interest the leader by Patrick White.1 I share his enthusiasm for smoking cessation and pulmonary rehabilitation. I do not, however, share his enthusiasm for inhaler therapy beyond short-term beta-agonists. The evidence for long-term reductions in exacerbations and admissions is there but it is hardly striking. I do not think that we should extrapolate reductions in mortality until that evidence is there. The fact that it is not already, suggests that any reductions, sadly, won’t be too great.
My concerns are that, once labelled the path of prescribing moves almost automatically to short-acting beta-agonists, long-acting beta-agonists, and inhaled steroids in all patients, even in those with mild disease and even in those with no objective or subjective hard evidence of improvement. How can we make treatment more objectively useful?
I do not want to be a therapeutic nihilist but equally this disease needs cost effective, evidence-based treatments that are re-assessed and stopped if they don’t work. A huge sum is being spent promoting the benefits of multiple treatments, but rarely do these promotions emphasise, for instance, the increased pneumonias in people with chronic obstructive pulmonary disease who are being treated with inhaled steroids.
- © British Journal of General Practice, 2010.
