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(Aust Prescr 1999;22:131-2)

Letters, which may not necessarily be published in full, should be restricted to not more than 250 words. When relevant, comment on the letter is sought from the author. Due to production schedules, it is normally not possible to publish letters received in response to material appearing in a particular issue earlier than the second or third subsequent issue.

Asthma treatments

Editor, - Professor Seale provides an informative and helpful account of the role of anti-leukotriene drugs in asthma (Aust Prescr 1999;22:58-60), contrasting with the somewhat irrational claims of their benefits in the lay press. It raises the issue of how to assess the benefits of asthma medication. A recent study¹ advocated use of inhaled budesonide to prevent asthma relapse following discharge from the emergency department. Improved outcomes were measured by reduced relapse (defined as unscheduled visits for worsening symptoms), improved scores on an Asthma Quality of Life Questionnaire, and improved symptom scores. However there were no differences between treatment groups in measures of peak expiratory flow rates. If there is no difference in measured respiratory function, what is the significance of the other outcome measures, and what is the optimum method to assess if a patient is helped by a new intervention? If a patient says they feel better, possibly from a placebo effect of a perceived `wonder drug', should they be continued on a new and expensive medication if there is no other measure of improvement?

Brendon Smith
Staff Specialist
Emergency Department
Sutherland Hospital
Caringbah, N.S.W.

Reference

1. Rowe BH, Bota GW, Fabris L, Therrien SA, Milner RA, Jacono J. Inhaled budesonide in addition to oral corticosteroids to prevent asthma relapse following discharge from the emergency department: a randomized controlled trial. JAMA 1999;281:2119-26.

Dr Helen Reddel, Research Scholar, Institute of Respiratory Medicine, Royal Prince Alfred Hospital and University of Sydney, comments:
Dr Smith raises an important issue about how we should assess response to asthma medications. As there is no `gold standard' for asthma, we need to assess both subjective (symptoms, quality of life) and objective (lung function, airway responsiveness) aspects of asthma control. A marked discrepancy between the results for different outcome measures may be due to methodological problems, as seems likely in the quoted study.

The methodology for assessing relapse rate, symptoms and quality of life in this study appear to be valid, but there may be problems with the assessment of lung function. The study was designed to examine risk of asthma exacerbations, so the most appropriate lung function measure would have been peak expiratory flow performed on waking, as `morning dipping' is associated with risk of asthma exacerbation. Lung function rises during the day even in poorly-controlled asthma, so spirometry measured at clinic visits (as in this study) would be less likely to show a difference between treatment groups. In addition, it is not clear from the paper whether lung function was measured in patients who experienced relapse and were therefore withdrawn before the 21 day assessment; if not, censoring of data from treatment `failures' would significantly reduce the chance of observing a difference in lung function between the groups.

Dr Smith's comments about the `placebo effect of a perceived "wonder drug'' ' highlight the importance of assessing the value of a new medication from a series of well-designed randomised controlled trials rather than
from anecdotal reports.

New drugs

Editor, - John Watson's professor of old, (`Letters' Aust Prescr 1999;22:77) used an important dictum about using new and old drugs, but he could not claim originality. I thought it was a paraphrase of a couplet in Polonius's advice to Laertes (Hamlet, by William Shakespeare) and my doctor brother Michael thought it was from Sir William Osler. The latter probably would have invented it if it had not been originally phrased by Pope, in his Essay on Criticism (lines 335-6):

` Be not the first by whom the new are tried
Nor yet the last to lay the old aside'.

David Grounds
Psychiatrist
Richmond, Vic.

Sertraline and statins

Editor, - Two issues arise from Vol 22, No. 5. The article by John Tiller ` The new antidepressants - clinical applications' (Aust Prescr 1999;22:108-11) omits reference to sertraline as an agent approved for treatment of panic disorder. Panic disorder has been an approved indication for sertraline since December 1997.

In the article by Eve Hurley `Assessing the statins' (Aust Prescr 1999;22:114-7) the self-test question 8, about primary prevention, correctly answered as `true', could amount to less than the `whole truth'. I suggest it would be more accurate to say that, based on studies reported to date, there is more evidence of benefit from statins in secondary prevention than there is in primary prevention (i.e. three trials versus one published to date). The statement offered is too absolute, and might get a pharmaceutical company into trouble with the Code of Conduct Committee if offered for promotional purposes.

M.M. Lawrie
Director, Medical Affairs
Pfizer Australia
West Ryde, N.S.W.