Managing chronic diseases

Editor—The long acting anticholinergic drug tiotropium and the long acting β-2 agonist formoterol have individually been shown to be effective in the management of chronic obstructive pulmonary disease (COPD).¹ Faster and prolonged action in case of formoterol and effective prolonged action of tiotropium make the two drugs with different profiles attractive alternative options, and combining them seems justified for patients with stable COPD.²,³

In India the combination of drugs is being used to good clinical benefit. People do not have to rely on multiple inhalers, which improves compliance with treatment. This is especially important for the vast illiterate population of India, for whom using inhalators to manage respiratory disorders is associated with taboos.

Most villagers believe that prescription of inhalers spells doom for the patient and that inhalers are prescribed only when the end is near. Doctors are finding it difficult to convince patients to use inhalers. Many doctors use the analogy “eyedrops for eyes, eardrops for ears, topical ointments for skin disorders, and inhalers for respiratory tract disorders” to make the point of using inhaler treatment to deliver the drug directly to the site of action rather than through a circuitous route.

Patients often fall prey to quacks and unlicensed practitioners who dispense potentially harmful drugs, and they report with serious systemic side effects such as Cushing's syndrome.⁴ Having combination therapy available helps ensure that the correct form of treatment is dispensed to patients in a convenient and easy manner. Public health organisations have to work hard to raise awareness about the inhalers, and a convenient combination certainly helps ensure better compliance.