Systematic review of clinical effectiveness of pressurised metered dose inhalers versus other hand held inhaler devices for delivering β2agonists bronchodilators in asthma
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7318.901 (Published 20 October 2001) Cite this as: BMJ 2001;323:901
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Editor of the BMJ
BMA house
Tavistock Square
London WC1J 9JR
UK
Dear Sir,
Recently, 2 outstanding systematic reviews on the clinical
effectiveness of pressured metered dose inhalers (pMDI) versus other hand
held devices for delivery of inhaled medication appeared in the journal
(1,2). By systematically evaluating randomised controlled trials on this
topic, the conclusion of these papers was almost the same for both inhaled
bronchodilators and inhaled corticosteroids: no evidence was found that
alternative inhaler devices (dry powder inhalers, breath actuated
pressurised metered dose inhalers) are more effective than the pMDI for
the delivery of inhaled medication. Therefore, pMDI remains the most cost
effective first-line device for administrating inhaled therapy (1,2).
Studies in both children and adults were analysed. Although we in general
subscribe this conclusion, we want to draw attention on a confusing
passage which is prone for drawing wrong conclusions from these reviews.
The authors discuss pressured metered dose inhalers with or without spacer
devices compared with alternative inhaled devices (page 900, line 16 from
above and page 902, line 7 from below). This is a somewhat unlucky
phrasing because the reader may conclude that pMDI with or without a
spacer does not make any difference in clinical effectiveness. In at least
one patient category this is certainly not true. It has been repeatedly
shown that pMDI in children under the age of 8 are only effective in
combination with a spacer device (3), which is also recommended in the
current guidelines (4). The use of a pMDI alone in young children will
give almost no lung deposition and therefore is useless. In our
experience, it still happens that physicians or parents use this wrong way
of administrating inhaled medication to children. Moreover, also elderly
patients with hand-lung co-ordination problems are likely to benefit from
the easiness of the combination of a pMDI with a spacer device (5). We
think that these aspects are an important addition to these excellent
reviews.
1. Brocklebank D, Wright J, Cates Christopher. Systematic review of
clinical effectiveness of pressurised metered dose inhalers versus other
hand held inhaler devices for delivering corticosteroids in asthma. BMJ
2001;322:896-900.
2. Ram Felix SF, Wright J, Brocklebank D, White John ES. Systematic review
of clinical effectiveness of pressurised metered dose inhalers versus
other hand held inhaler devices for delivering beta-2 agonist
bronchodilators in asthma. BMJ 2001;323:901-905.
3. Bisgaard H. Delivery of inhaled medication to children. J Asthma
1997;34:443-467.
4. Chernick V, Boat TF, Kendig Jr EL. Kendig’s disorders of the
respiratory tract in children, 6th edition, page 718-719, WB Saunders
Company, London, 1998.
5. Ikeda A, Nishimura K, Izumi T. Pharmacological treatment in acute
exacerbations of COPD (review). drugs Aging 1998;12:129-137.
Edward Dompeling, MD, PhD1,2
Han Hendriks, MD2
Quirijn Jöbsis, MD, PhD2
Professor Raymond Donckerwolcke1
1 Dept. of Paediatrics and 2 Dept. of Paediatric Pulmonology,
University Hospital of Maastricht, PO Box 5800, 6202 AZ Maastricht,
Netherlands
Correspondence: E. Dompeling (phone ++31-43-3875284, fax ++31-43-
3875246, e-mail: edom@skin.azm.nl)
Competing interests: No competing interests
Bronchodilators, Corticosteroids and leukotriene antagonists in Indian Asthmatics
Inhalation of bronchodilators and corticosteroids is the mainstay of
treatment for patients with asthma. Many inhaler devices and drug
combinations are now available in India, and competing promotional claims
confuse both prescribers and patients. The cost of the drug used in
specific devices differs greatly. International guidelines are
inconsistent in their recommendations for prescribing inhaler devices in
different age groups. It’s strange that there are no National guidelines
for the management of asthma by Indian doctors for Indian patients thus
treating physicians are as confused as patients. Thus more and
pharmaceutical companies are coming out with inhalers and other devices;
some of them without any scientific rationale.
Recently, pharmaceutical industries have launched leukotriene-
modifying drugs without any definite clinical trial in Indian patients and
after reading some conflicting reports about the efficacy of these drugs
the Indian doctors have become more confused. I strongly feel that Indian
patients should have been included in the multicentre, multinational,
double-blind clinical trial to know the efficacy of new antiasthmatic
drug.
Competing Interests: None
Competing interests: No competing interests