• COPD Pharmacology

We read with interest your ‘Highlights from this Issue’ in the November issue of Thorax.1 We noticed that you had a fresh comment on Global Initiative for Obstructive Lung Diseases (GOLD) not recommending macrolides to prevent exacerbations of chronic obstructive pulmonary disease (COPD).

We also noted that you hinted that it was probably too cheap for GOLD—suggesting that we were in the pockets of ‘big pharma’. We find the remark hurtful and wrong. GOLD does receive funding from the pharmaceutical industry—as do most of the major respiratory scientific societies and journals through advertising—but none of the people working with the GOLD document receives money for the work performed. In addition, GOLD has a steady income from sales of GOLD material and this income is sufficient to fund the work by the scientific committee, mainly expenses related to meetings at airport hotels.

However, we are much more interested in how the editors would have dealt with the evidence for macrolides in a global COPD strategy document.

As the UK has National Institute of Clinical Excellence (NICE), other well-off countries have bodies that advise and regulate on drug use. However, most developing countries do not and many rely on documents like GOLD to form policies. Does the world—including developing countries—really need promotion of more widespread use of antibiotics that in a year will lead to 80% of its users having throat swabs with macrolide-resistant bacteria and no information whatsoever on the impact on the spread of resistance in the community? What drug and dose should we have recommended: azithromycin 250 mcg once daily for years? Should we advise that everybody had ECGs, hearing tests and monitoring of liver enzymes—and how do the editors think this would work in the real world? Should we follow advice from US colleagues in NEJM2 advocating 250 mg three times a week as a follow-up to the paper by Albert et al3 without any firm evidence that this dose has comparable efficacy? We felt that these questions precluded currently recommending use of macrolides despite some evidence of efficacy.

We would appreciate the assistance of the editors here—as would most people whose decisions were labelled ‘bizarre’ in Thorax.