• COPD Pharmacology

There was once an Editor of a paper in the far west who was sitting at his desk, musing pleasantly on life, when a bullet crashed through the window and embedded itself in the wall at the back of his head. A happy smile lit up the Editor's face. ‘Ah’, he said complacently, ‘I knew that Personal column of ours was going to be a success!’ What the bullet was to the Far West editor, the letter of Drs Vestbo and Rodriguez-Roisin to Thorax was to the undersigned (Modifed from Psmith, Journalist, by P G Wodehouse).

Vestbo and Rodriguez-Roisin1 appear pained (another Wodehouse-ism) at our references to PHARMA, finance and GOLD. We invite readers to visit http://www.goldcopd.org/sponsors.html to see a list of GOLD Pharma sponsors (with a direct link from the GOLD website to their home pages) and also http://www.goldcopd.org/disclosure-statements.html to see individual disclosures; we leave it to them to judge both the appropriateness or otherwise of these relationships and also of our comments. We are very happy to offer assistance with regard to macrolides, as requested, and can certainly offer them more than the brief statement that GOLD seems to feel is all the subject merits. There are indeed safety issues and uncertainty about optimum dose but these need to be interpreted in the light of the very compelling evidence of efficacy in a population who have a high unmet need.2 COPD lung attacks are serious events which contribute to the progression of disease and have a high risk of recurrence even on current optimum therapy.3 Treatment with low-dose macrolides is associated with an equivalent or greater reduction in the risk of COPD lung attacks than combination treatment4 or long-acting antimuscarinics,5 both of which are associated with adverse events but are enthusiastically endorsed by GOLD. Efficacious new treatments are scarce, but existing treatments might profitably be used in a smarter, more targeted way. This is what is so exciting about macrolides, which work best in patients with neutrophilic airway diseases, a population that respond poorly to corticosteroids.6 All of this and more could and should have featured in the GOLD guidelines and we still feel it is bizarre that it wasn't. This is an issue which does need to be debated; we are more than happy to hear the views of others.