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East Tennessee Pulmonary Associates Oak Ridge, TN
Correspondence to: Glenn D. Crater, Jr., MD, FCCP, East Tennessee Pulmonary Associates, 200 New York Ave, Suite 210, Oak Ridge, TN 37830; e-mail: gcmd{at}alumni.wfu.edu
To the Editor:
With regard to the article by Truit et al (January 2003),1 I would like to raise the following concerns: this was a retrospective study; the placebo factor and other confounding factors were not taken into account; other differences in treatments were not considered; and sicker patients were enrolled in the control group.
In retrospective studies, care must be taken to ensure that nothing changed between the two treatment groups. During this study, the pressure to treat patients in the outpatient setting may have changed, and new medications were introduced. Additionally, the physicians changed the protocol, suggesting that they believed the medication was safer and more effective, and perhaps was influencing them to send patients home earlier. Furthermore, the authors admit that they cannot track other treatments that may have changed.
When a therapy is changed in the "real world," there are always questions from patients. It would be interesting to know how this change was presented to the patients. I doubt that my patients who are accustomed to treatment every 4 h would graciously accept a reduction of those treatments by half without some explanation.
Another concern is reference 6, a letter that was published in Lancet, which is quoted as evidence that S-albuterol is potentially dangerous. Before we discard a drug that is cheap, safe, and effective, we should use articles that have been peer-reviewed and the data in which are reproducible.
In regard to the patients in the study, it appears that asthma patients were overrepresented when racemic albuterol was used (28% vs 18%, respectively). Also, these patients had a lower FEV1 at hospital admission (44.6% predicted vs 48.6% predicted, respectively), suggesting that they were sicker and required more interventions.
Furthermore, despite receiving albuterol on hospital discharge, the authors cite a reduction in 30-day readmission rates for the levalbuterol group. Are the authors suggesting that the effects of the drug last for 30 days? Notably, none of the asthmatic patients in the racemic albuterol group required readmission!
This article may question the dosing of albuterol every 4 h. Perhaps dosing every 8 h, in some patients, would be just as effective. And perhaps the best treatment is bronchodilator use only when a patient is symptomatic as a result of bronchospasm.
Footnotes
Dr. Crater is a reviewer for CHEST and is in the Speakers Bureau for GlaxoSmithKline.
References
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