Mucolytics useful for COPD, guidelines say
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《英国医生杂志》
Doctors need to be much more aware of the possibility of chronic obstructive pulmonary disease (COPD), particularly among current and former smokers, new clinical guidelines say.
Half of the estimated 1.5 million people in the United Kingdom with the disease remain undiagnosed. It is the fifth commonest cause of death in England and Wales, accounting for nearly 28 000 deaths every year.
The guidelines were developed for the National Institute for Clinical Excellence (NICE) by the National Collaborating Centre for Chronic Conditions, to raise standards of care for people with the condition and plug gaps in service provision.
They update guidance from the British Thoracic Society published in 1977 and emphasise the need for more effective initial diagnosis and management of acute episodes, the provision of pulmonary rehabilitation services, and the importance of multidisciplinary care.
The guidelines tell doctors to recognise that COPD could be a diagnosis in smokers and former smokers over the age of 35 with exertional breathlessness, chronic cough, and frequent winter "bronchitis."
The guidelines also dispense with the stepwise approach to treatment advocated in previous guidance, on the grounds that an individually tailored approach is likely to control symptoms more effectively.
But more controversially, the guidelines suggest that in most cases COPD can be diagnosed on the basis of a good history and spirometry to confirm obstructed airflow, without the need to assess changes in lung strength (forced expiratory volume in 1 second) in response to a single dose of inhaled bronchodilator. Not all health professionals dealing with COPD currently have access to spirometry or are adequately trained in its use.
The guidelines also recommend that doctors should prescribe long acting bronchodilators, inhaled corticosteroids, and mucolytics for persistent symptoms. Previous research has suggested that inhaled corticosteroids confer no benefit; and until recently, GPs have not been able to prescribe mucolytics on the NHS, despite widespread use in Europe.
But Dr David Halpin, who chaired the Guideline Development Group, writes in the journal Thorax (2004;59:181-2), that the evidence for inhaled corticosteroids to prevent further acute episodes of COPD has become clearer.
And he says of mucolytics: "There is good evidence of their efficacy in reducing exacerbations and improving symptoms in patients with chronic bronchitis, and some direct evidence of benefits in patients with COPD."
"In the absence of a National Service Framework for respiratory medicine, and the reality that such a framework is unlikely to be introduced in the near future, these NICE guidelines offer the best hope of raising the standards of care of this common disabling chronic disease," he writes.(London Caroline White)
Half of the estimated 1.5 million people in the United Kingdom with the disease remain undiagnosed. It is the fifth commonest cause of death in England and Wales, accounting for nearly 28 000 deaths every year.
The guidelines were developed for the National Institute for Clinical Excellence (NICE) by the National Collaborating Centre for Chronic Conditions, to raise standards of care for people with the condition and plug gaps in service provision.
They update guidance from the British Thoracic Society published in 1977 and emphasise the need for more effective initial diagnosis and management of acute episodes, the provision of pulmonary rehabilitation services, and the importance of multidisciplinary care.
The guidelines tell doctors to recognise that COPD could be a diagnosis in smokers and former smokers over the age of 35 with exertional breathlessness, chronic cough, and frequent winter "bronchitis."
The guidelines also dispense with the stepwise approach to treatment advocated in previous guidance, on the grounds that an individually tailored approach is likely to control symptoms more effectively.
But more controversially, the guidelines suggest that in most cases COPD can be diagnosed on the basis of a good history and spirometry to confirm obstructed airflow, without the need to assess changes in lung strength (forced expiratory volume in 1 second) in response to a single dose of inhaled bronchodilator. Not all health professionals dealing with COPD currently have access to spirometry or are adequately trained in its use.
The guidelines also recommend that doctors should prescribe long acting bronchodilators, inhaled corticosteroids, and mucolytics for persistent symptoms. Previous research has suggested that inhaled corticosteroids confer no benefit; and until recently, GPs have not been able to prescribe mucolytics on the NHS, despite widespread use in Europe.
But Dr David Halpin, who chaired the Guideline Development Group, writes in the journal Thorax (2004;59:181-2), that the evidence for inhaled corticosteroids to prevent further acute episodes of COPD has become clearer.
And he says of mucolytics: "There is good evidence of their efficacy in reducing exacerbations and improving symptoms in patients with chronic bronchitis, and some direct evidence of benefits in patients with COPD."
"In the absence of a National Service Framework for respiratory medicine, and the reality that such a framework is unlikely to be introduced in the near future, these NICE guidelines offer the best hope of raising the standards of care of this common disabling chronic disease," he writes.(London Caroline White)