Reply to Mahler et al.: Pharmacotherapy for Chronic Obstructive Pulmonary Disease: Molecules and Delivery Are Equally Important

From the Authors:

We would like to thank Drs. Mahler, Ohar, Ferguson, and Donohue for their interest in the “Pharmacologic Management of Chronic Obstructive Pulmonary Disease: An Official American Thoracic Society Clinical Practice Guideline” (1). We wholly agree with the points raised with respect to the need to address medication delivery systems for clinical decision-making. Our Clinical Practice Guideline relied on the available literature to date to perform a rigorous, PICO (Population, Intervention, Comparator, and Outcomes)-driven distillation of scientific evidence to provide recommendations pertaining to key questions regarding the pharmacologic treatment of chronic obstructive pulmonary disease. However, the available evidence did not allow us to address the merits of specific medication delivery devices. As per the committee discussions, we raised the issues of feasibility and acceptability as playing a role in the decision to prescribe various types of inhalers. Though we noted issues such as cost and burden of use of inhalers, we did not specifically identify cognitive ability, dexterity, coordination, and inspiratory flow as additional issues to be addressed. We thank the authors for raising these important considerations in this forum and look forward to future randomized trials that address matching medication delivery devices to specific patient characteristics.