A collaboration of multidisciplinary experts on the delivery of pharmaceutical aerosols was facilitated by the European Respiratory Society (ERS) and the International Society for Aerosols in Medicine (ISAM), in order to draw up a consensus statement with clear, up-to-date recommendations that enable the pulmonary physician to choose the type of aerosol delivery device that is most suitable for their patient. The focus of the consensus statement is the patient-use aspect of the aerosol delivery devices that are currently available. The subject was divided into different topics, which were in turn assigned to at least two experts. The authors searched the literature according to their own strategies, with no central literature review being performed. To achieve consensus, draft reports and recommendations were reviewed and voted on by the entire panel. Specific recommendations for use of the devices can be found throughout the statement. Healthcare providers should ensure that their patients can and will use these devices correctly. This requires that the clinician: is aware of the devices that are currently available to deliver the prescribed drugs; knows the various techniques that are appropriate for each device; is able to evaluate the patient's inhalation technique to be sure they are using the devices properly; and ensures that the inhalation method is appropriate for each patient.

/pdf/what-the-pulmonary-specialist-should-know-about-the-new-w0lq2cl6e7.pdf

What the pulmonary specialist should know about the new inhalation therapies

ContextIncreasing contact has been reported between physicians and the pharmaceutical
industry, although no data exist in the literature regarding potential financial
conflicts of interest for authors of clinical practice guidelines (CPGs).
These interactions may be particularly relevant since CPGs are designed to
influence the practice of a large number of physicians.ObjectiveTo quantify the extent and nature of interactions between authors of
CPGs and the pharmaceutical industry.Design, Setting, and ParticipantsCross-sectional survey of 192 authors of 44 CPGs endorsed by North American
and European societies on common adult diseases published between 1991 and
July 1999. One hundred authors (52%) provided usable responses representing
37 of 44 different CPGs that we identified.Main Outcome MeasuresNature and extent of interactions of authors with drug manufacturers;
disclosure of relationships in published guidelines; prior discussion among
authors regarding relationships; beliefs regarding whether authors' own relationships
or those of their colleagues influenced treatment recommendations in guidelines.ResultsEighty-seven percent of authors had some form of interaction with the
pharmaceutical industry. Fifty-eight percent had received financial support
to perform research and 38% had served as employees or consultants for a pharmaceutical
company. On average, CPG authors interacted with 10.5 different companies.
Overall, an average of 81% (95% confidence interval, 70%-92%) of authors per
CPG had interactions. Similarly, all of the CPGs for 7 of the 10 diseases
included in our study had at least 1 author who had some interaction. Fifty-nine
percent had relationships with companies whose drugs were considered in the
guideline they authored, and of these authors, 96% had relationships that
predated the guideline creation process. Fifty-five percent of respondents
indicated that the guideline process with which they were involved had no
formal process for declaring these relationships. In published versions of
the CPGs, specific declarations regarding the personal financial interactions
of individual authors with the pharmaceutical industry were made in only 2
cases. Seven percent thought that their own relationships with the pharmaceutical
industry influenced the recommendations and 19% thought that their coauthors'
recommendations were influenced by their relationships.ConclusionsAlthough the response rate for this survey was low, there appears to
be considerable interaction between CPG authors and the pharmaceutical industry.
Our study highlights the need for appropriate disclosure of financial conflicts
of interest for authors of CPGs and a formal process for discussing these
conflicts prior to CPG development.

/pdf/relationships-between-authors-of-clinical-practice-4ca5yye055.pdf

Relationships between authors of clinical practice guidelines and the pharmaceutical industry.

The aim of this study was to compare the effects of salmeterol and beclomethasone on lung function and symptoms in children with mild to moderate asthma. Sixty-seven children not treated with inhaled corticosteroids were randomized in a double-blind parallel study either to salmeterol 50 micrograms b.i.d. or beclomethasone 200 micrograms b.i.d. After one year, FEV1 significantly increased in the beclomethasone group, whereas in the salmeterol group there was a small reduction. Differences between groups were 14.2% predicted (p < 0.0001) and 7.0% predicted (p = 0.007) for pre- and postbronchodilator FEV1 values, respectively. PD20 methacholine decreased by 0.73 DD (p = 0.05) in the salmeterol group and increased by 2.02 DD (p < 0.0001) in the beclomethasone group. Morning and evening PEF and symptom scores improved in both groups, although more in the beclomethasone group. Asthma exacerbations, for which prednisolone was needed, were more frequent in the salmeterol group (17 versus two), as were the number of withdrawals due to exacerbations (six versus one). However, growth was significantly slower in the beclomethasone group (-0.28 SDS) compared with that in the salmeterol group (-0.03 SDS) (p = 0.001). We conclude that treatment with a moderate dose of beclomethasone is superior to salmeterol in children with mild to moderate asthma and recommend that salmeterol should not be used as monotherapy.

/pdf/one-year-treatment-with-salmeterol-compared-with-456b5u7l3r.pdf

One Year Treatment with Salmeterol Compared with Beclomethasone in Children with Asthma

Theophylline has been used for several decades in the treatment of asthma and remains the most widely prescribed anti-asthma drug worldwide, although the development of newer anti-asthma medications, especially inhaled steroids, has resulted in declining use of theophylline in industrialized countries. Theophylline is now considered to be a bronchodilator, but it is increasingly recognized that theophylline has other anti-asthma activities, which may be more important. Theophylline, even at low plasma concentrations, inhibits the late asthmatic reaction following allergen challenge. These clinical pharmacological observations are substantiated by experimental animal and in vitro data showing that theophylline has several anti-inflammatory activities relevant to asthma. These include the inhibition of cytokine synthesis and release, the inhibition of inflammatory cell activation and microvascular leakage, and the prevention of airway hyperresponsiveness induced by airway inflammation. Theophylline appears to have immunomodulatory effects, even at relatively low plasma concentrations. Based on these considerations, theophylline can be regarded as a useful alternative to other anti-inflammatory drugs for the chronic treatment of mild to moderate asthma. Theophylline should be used at lower doses to achieve plasma concentrations of 5-10 mg.l-1, which will avoid the risk of side-effects. Further studies are required to evaluate the role of low-dose theophylline as an adjunct to low-dose inhaled steroids in the management of chronic asthma. It may now be appropriate to re-evaluate the role of theophylline in asthma management.

https://erj.ersjournals.com/content/erj/7/3/579.full.pdf

Theophylline in the management of asthma: time for reappraisal?

An increased concentration of nitric oxide (NO) in the exhaled air of asthmatic patients may reflect inflammation of the airways, and exhaled NO may, therefore, be useful in monitoring asthma control and the optimal use of anti-inflammatory treatment. We have studied the effect of reducing and then increasing the dose of inhaled steroid on exhaled NO, lung function and symptoms in 14 asthmatic patients treated with twice daily budesonide. Baseline measurements were made at the end of a 2 week run-in period, 2 weeks after the daily dose of budesonide was reduced by 200 micrograms daily, and 2 weeks after the dose was then increased by 200 micrograms daily. Exhaled NO increased significantly compared with baseline after the dose was reduced by 200 micrograms daily (from 122 +/- 13 to 246 +/- 52 ppb); whereas, there was no significant decrease in spirometry or change in peak flow variability. There was also a significant increase in symptoms at night, but no change during the day or in the number of rescue doses of inhaled beta 2-agonist. The level of exhaled NO decreased when the dose of inhaled steroids was increased, and this was associated with a reduction in diurnal variability of peak expiratory flow, and in nocturnal symptoms. Our study suggests that exhaled nitric oxide may be a useful means of monitoring control of asthma. Further longitudinal studies in patients of differing asthma severity are now indicated.

https://erj.ersjournals.com/content/erj/9/2/196.full.pdf

Changes in the dose of inhaled steroid affect exhaled nitric oxide levels in asthmatic patients

papillary necrosis. Such patients will not present with renal failure if the contralateral kidney functions normally, and under these circumstances the diagnosis of an obstructed pyonephrosis can easily be delayed, with potentially serious consequences for renal function. If acute obstruction is suspected in the presence of infection a negative ultrasonogram is of no clinical value (and, as Dr Webb implies, a dilated collecting system will require further evaluation by other means). Such patients deserve urography, and if this shows a "non-functioning" kidney antegrade pyelography should be carried out, which can be followed by percutaneous drainage if obstruction is present. STEPHEN J AUSTIN

https://www.bmj.com/content/bmj/301/6763/1276.3.full.pdf

Guidelines for management of asthma.

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Guidelines for management of asthma.