TORCH: Towards a Revolution in COPD Health? Not really.

Last month, the long-awaited results of the TORCH study of Advair (aka Seretide outside the U.S.)(TM) for patients with moderate to severe COPD were published, but were no doubt disappointing to patients with COPD and investors who own GSK stock. Optimists spun the results as "positive" with a 17% relative reduction in death rates for those taking the combination inhaler for 3 years when compared to those taking the placebo inhaler. However, the absolute difference in deaths during the 3 years from any and all causes was only 2.6% (12.6% vs 15.2%) and this small difference was not statistically significant.

An Advair Diskus 500/50mcg (the high dose used by the TORCH study) costs about $270 per month. The drug was associated with a lower hospitalization rate for COPD exacerbations, but 32 patients (or their insurers) would each have to pay about $3200 per year (over $100,000 total) to prevent just one of these hospitalizations.

But doesn't taking the combo inhaler make the patients feel better? Well, after taking Advair for one year, about half of them did generally feel noticably better than those taking the placebo inhaler, according to scores on a standardized COPD questionnaire (St. Georges). However, over the next two years, the disease progressed in all patients as their lung function fell further and they became more short of breath. Those taking the inhaled corticosteroid (fluticasone), either alone or in the combo inhaler, were also significantly more likely to get pneumonia (a serious side-effect). I'm personally not as optimistic (or biased) as my colleagues who were paid to participate in the study, one of whom said, "We clearly showed that the combined treatment helps prevent disease-related exacerbations and helps people feel better. But does it help them live longer? We can't say for sure; but we think it does."

About half of the patients had been taking a COPD inhaler before they entered the study, so it's not surprising that over six billion dollars was spent on Advair inhalers last year (for asthma or COPD), plus billions for Spiriva or Atrovent COPD inhalers.

I worry that patients believe that these inhalers are "curing" their lung disease and that they don't have to take the effort to stop smoking. Forty percent of the 6000 COPD patients in the TORCH study were still smoking, despite their advanced lung disease due to their habit. Sadly, I think that doctors are taking the easy ten second "solution" of writing a prescription for an expensive inhaler instead of the time-consuming counseling over several visits needed to help a nicotine addict to quit. Smoking cessation is the only intervention proven to slow the progression of COPD. It has been proven several times that inhalers are not the cure for COPD.

Related Topics:

• Quit Smoking: Your Guide to Kicking the Habit
• WebMD Message Board: Smoking Cessation Support Group

Technorati Tags: COPD, chronic obstructive pulmonary disease, Advair, smoking cessation, healh-and-wellness

Updated Asthma Guidelines

Every five years, guidelines for physicians who diagnose and treat asthma are updated by the NAEPP's Expert Panel to incorporate newly published evidence from research studies. Last weekend in San Diego I attended the largest allergy meeting in the world, the annual congress of the AAAAI, where the 2007 update of the asthma guidelines was presented by some of the panel members. The full 600-page document is available for downloading and public comments before March 15. One of the panel members, only half-joking, said that the only people who have commented on previous drafts are employees of asthma drug companies who believe that their drug should have received more emphasis. About 20 of the 4000 allergists at the meeting stood at the microphones to ask questions of the panel members during the final 30 minutes of the session.

Here are some key differences between the 2007 guidelines and previous editions.

• Current asthma treatments do not prevent disease progression.
• Even patients with intermittent asthma can have severe asthma attacks (exacerbations). S
• Single steps taken to reduce indoor allergen levels (such as just buying an air cleaner or just using allergen-proof bedding) are generally ineffective.
• Formaldehyde and VOCs (chemicals that smell funny) can worsen asthma.
• Every patient with asthma should have a written asthma action plan which includes both daily management and early recognition of asthma exacerbations.
• When a patient is regularly taking an ICS, but still has inadequate asthma control (remains in the yellow zone), the addition of a LABA (like salmeterol or formoterol) may be a better option than doubling the daily ICS dose.

Recommended emergency room management of asthma attacks was updated.

• Levalbuterol (Xopenex) may be used instead of traditional racemic (inexpensive) albuterol.
• For severe attacks not responding to traditional therapy, magnesium sulfate or heliox therapy should be considered.
• Ipratropium (Atrovent) is no longer recommended for hospital inpatient asthma therapy.
• A primary goal of ER therapy (before the patient is sent home with an ICS and other therapy) is an FEV1 of more than 70% of the predicted (normal) value.

Sadly, it may take years before the doctors who treat you for asthma incorporate these new guidelines into their routine practice. For example, large studies have shown that fewer than half of patients were taking an ICS (the best asthma controller therapy) during the three months after an asthma attack.

Related Topics:

WebMD Video: Asthma Medication Tips

WebMD Video: Asthma and Ozone

Technorati Tags: asthma, asthma action plan, treatment guidelines, salmeterol, formoterol, albuterol, Levalbuterol, Xopenex, health-and-wellness