Dear Colleagues,
Here are Douglas Newberry's further comments.
All good wishes,
Olive
>>> "Douglas Newberry" <[log in to unmask]> 17/03/2007 21:25 >>>
[log in to unmask] wrote Olive Goddard wrote 7/3/07:
Dear Olive,
Thank you for forwarding the thoughtful and well referenced comments
of
Neal Maskrey. He writes a helpful summary of a complicated and
interesting area.
Three further points:
A: Cost: the LABA and LABA-combination products remain expensive to
the
NHS (and in the US), whereas with budesonide and fluticasone coming
off
patent, even high-dose inhaled steroids are now significantly cheaper
than LABA-combinations. Our patients are fortunate that this is not a
crucial issue.
B: relevant comparison - TIMING and HOW MUCH TO INCREASE DOSE OF ICS
for
Acute Exacerbation: Many of the comparison studies of higher-dose ICS
vs
lower dose ICS + LABA are flawed by two weakness in the ICS arm of the
studies:
1: Asthma is highly variable in the individual over time. The patient
knows first when when they are getting symptoms, so a "Patient
Initiated" (big) increase in therapy works more effectively with less
side effect than a (moderate) long term increase in ICS.
2: Doubling the dose of ICS in acute asthma exacerbations is not very
efficatious, whereas a fivefold increase in the dose is highly
effective. This is not an unrealistic increase if patients are allowed
to reduce their dose when they have FULLY controlled symptoms (many
patients do this even is advised not to).
The majority of industry funded studies showing the advantages of LABA
used the (known to be ineffective) comparator of a long-term doubling
of
dose of ICS, rather than a patient initiated, shorter duration and
higher/more effective increase in dose of ICS.
C: Changing side effect profile with recently available Ciclesonide.
This ICS is priced at a level competitive with pulmicort and flixotide
(without LABA) and has good evidence for selective lung activity so
side
effects are reduced. It uses the same MDI as QVAR, so also claims 52%
lung deposition compared to 28% for turbohaler, 25% for
mdi+areochamber-
plus, 12% for pulmicort/flixotide mdi without spacer and 4-10% for
generic beclomethasone mdi without spacer.
In the clinic, if patients really like a particular formulation, this
is
likely to outweigh other considerations, exactly as Neil concludes in
his four domains of effectiveness analysis.
Thank you for facilitating another really interesting exchange.
Regards
Douglas
--
Dr. Douglas Newberry, MD, MSc, FRCP,
Consultant Respiratory Physician,
Princess Alexandra Hospital,
Hamstel Road, Harlow, Essex, CM20 1QX
GMC No. 3595659
mobile 077 11 44 0627
Respiratory Secretary- Sarah Byrne 01279 82 7419 on
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or Jenny Donovan on 01279 4444 55 ext 2665
Please use the following email to reach me:
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