tag:blogger.com,1999:blog-9143719926358099859.post8469100408619036524..comments2023-10-26T08:08:43.486-07:00Comments on Dr. Mintz' Blog: Bad news for COPD: Why this meta-analysis should be believed (and the Avandia one should not)Dr. Matthew Mintzhttp://www.blogger.com/profile/01058182168282244996noreply@blogger.comBlogger5125tag:blogger.com,1999:blog-9143719926358099859.post-50552684586825095262008-11-09T19:25:00.000-08:002008-11-09T19:25:00.000-08:00Dr. Mintz, I regret not locating your other posts ...Dr. Mintz, <BR/><BR/>I regret not locating your other posts regarding this topic. Thank you for bringing it to my attention. I appreciate that you have looked at this anticholinergic issue from both sides, an activity in which we all should engage when discerning appropriate long-term maintenance therapies for our patients. <BR/><BR/>I personally have become an advocate of anticholinergic therapy prior to ICS/LABA. Cholinergic tone represents a major reversible component of COPD. In the literature, long-acting anticholinergic treatment has been shown to provide superior bronchodilation compared to LABA. In addition, patients have displayed tolerance to long-term beta agonist therapy. <BR/><BR/>Also, I like to reserve steroid therapy until I have no other options due to known long-term issues. Considering the anticholinergic first approach, I do not hesitate to give LABA/ICS if the anticholinergic does not provide adequate relief. Age of the patient also plays a role in my decision.<BR/><BR/>Thank you for the forum to express approaches to treatment and even differing viewpoints. After all, we are striving to achieve the same objective, helping patients.<BR/><BR/>Dr. Bruce ChesterAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-9143719926358099859.post-76406112303468422922008-10-25T17:28:00.000-07:002008-10-25T17:28:00.000-07:00Dr. Chester, Thanks for your comments. The meta-a...Dr. Chester, <BR/>Thanks for your comments. The meta-analysis was far from perfect. As I mentioned in this post, "If you are taking ipratoprium (Atrovent) there are likely better alternatives ... If you are taking Spiriva, don't stop! ... There is also great risk for poorly controlled COPD, and several studies that show Spiriva reduces exacerbations. The UPLIFT study is currently underway, and may have reasurring data about Spiriva." <BR/>Please also note my post following the UPLIFT study called "UPLIFTing News for COPD."<BR/>I think Spiriva is a great drug, I use it in many of my COPD patients, and will continue to do so. I think the real question is whether or not ICS/LABA should be used first followed by Spriva, or the other way around as guidelines currently suggest.Dr. Matthew Mintzhttps://www.blogger.com/profile/01058182168282244996noreply@blogger.comtag:blogger.com,1999:blog-9143719926358099859.post-3702877229728588042008-10-23T19:42:00.000-07:002008-10-23T19:42:00.000-07:00The Uplift data and the detailed analyses of 29 ot...The Uplift data and the detailed analyses of 29 other PROSPECTIVE, placebo controlled trials with tiotropium contradict this meta-analysis. In addition, the blind faith in this meta-analysis fails to recognize its falacies. An apparent double counting of approximately 1000 patients took place, thereby rendering any statistical analysis inaccurate. <BR/><BR/>Also, the term "meta" means "many." However, the majority of the data from the analysis was pulled from a SINGLE study, the Lung Health Study. Interestingly, results were published for patients who had stopped taking medication and questions have been raised about including placebo and active comparator patients into the same grouping. <BR/><BR/>Furthermore, with funding provided by a competing drug company, we as practitioners have to question the motivation behind the publishing and also ask hard questions of our beloved JAMA publication for its lack of scrutiny. <BR/><BR/>Millions of patients worldwide have had their lives positively changed by tiotropium, dwarfing the numbers of those who may have been harmed. We all know the horrid consequence of a progressive disease such as COPD. Let's stop striking panic and fear into patients and educate them on the risk and benefits of therapies. After all, have you stopped recommending Tylenol? Think about it.....<BR/><BR/>Dr. Bruce ChesterAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-9143719926358099859.post-28677818292430648812008-09-25T19:28:00.000-07:002008-09-25T19:28:00.000-07:00First, there is no such thing as a "black box." Th...First, there is no such thing as a "black box." This is a term created by the media. A "boxed warning" is a warning added to the label of a medication that is generally at the top and has a box around it. There is nothing "black."<BR/>The boxed warning on Advair comes from a study on salmeterol, one of the components of advair. I go into great detail on all the data regarding this on a previous post called <A HREF="http://drmintz.blogspot.com/2008/06/good-new-for-asthma-patients.html" REL="nofollow"> Good News for Asthma Patients </A>. The bottom line is that safety concerns are really only an issue with salmeterol is taken alone. When taken together with fluticasone (Advair is fluticasone +salmeterol) not only is it safe, but it is also one of the most effective medications for asthma. Since the introduction of medications like Advair the asthma death rate has declined. That, coupled with the fact that Advair in COPD patients may have actually prevented deaths suggest the medicine is safe. <BR/>The real question now is whether or not severent should be used alone in COPD. It clearly shouldn't be for asthma, but can be for COPD. Currently guidelines (which may change with this new data) recommend a bronchodilator as first line therapy. However, if you choose not to use ipra or tiotropium because if this study this leaave you with a LABA like salmeterol. On the one hand, the TORCH study did not show an increase harm rate in severent taken alone, on the other hand the data on serevent taken alone with asthmatics is worrisome. This raises the question of whether ICS/LABA (Advair, Symbicort) should be used not just in severe disease (as recommended by current guidelines), but earlier in mild to moderate disease, reserving Spiriva only when the ICS/LABA isn't working. I don't know what the guideline makers will decide, but this is where I am leaning. (Though, as above, I wouldn't recommend stopping Spiriva for now).Dr. Matthew Mintzhttps://www.blogger.com/profile/01058182168282244996noreply@blogger.comtag:blogger.com,1999:blog-9143719926358099859.post-7915308008138365972008-09-25T18:27:00.000-07:002008-09-25T18:27:00.000-07:00And what about Advair's black box warning?And what about Advair's black box warning?Anonymousnoreply@blogger.com