Thank you for your recent and excellent series on COPD in the March issue of BCMJ [2008;50:78-102 [9]]. Many excellent points were raised. I am looking forward to the April issue.

Recent studies seem to “hyper-inflate” the benefit and dismiss the potential harm of long-acting inhaled bronchidilator and corticosteroid treatments. 

For instance, in the recent Advir trial, TORCH, the benefit was strongly promoted even though it was not statistically significant, yet the harm received very little discussion; the risk of dying over the 3-year study duration was not reduced (P>.052 vs placebo, and much less significant compared with either agent alone), there was not a clinically significant improvement in quality of life, and the risk of treatment-induced pneumonia was nearly doubled (19.6% vs 12.3%, P<.001, RRI 59%, ARI 7.3%, OR 1.59, NNH 14). 

There is active debate regarding the use of ß2 agonists in COPD (Canadian Family Physician, August and September 2007, pp. 1290 -1293 and pp. 1429-1430 respectively).

I am familiar with the pharmacological treatment ladder for COPD and the role for spirometry. I agree that “significant response to bronchidilator is… uncommon in COPD.” 

So I need to ask, when it is documented by spirometry that this patient has had no significant response to bronchidilator therapy and given that the literature reveals the above, why do the guidelines recommend such treatment? Are we overprescribing and doing them a disservice?

—Richard Beever, MD
Fraser Lake