Physicians who spend their lives treating patients have always lived with the social representations of health, disease, and medication. These social representations are construct images of a natural reality and are as old as the disease itself. Based on affective and cognitive predispositions, and often inhabited by fears, beliefs, and magical and supernatural elements, the function of social representations is to make something unusual and unknown familiar to the patient.

Chronic obstructive pulmonary disease (COPD) and inhaled medications do not escape these social representation systems. The theory of social representations was first formulated by social psychologist Serge Moscovici in a paper published in France in 1961.1 I wonder, however, if COPD is not itself also represented in doctors who usually treat this complex disease in hospitals or in primary health care, and if their representation is haunted by dogmas and medical beliefs.

In COPD, as in many other chronic diseases, non-adherence to medication is a critical issue.2 Non-adherence to inhaled therapy in COPD has been called a high magnitude problem and a major factor of therapeutic failure, but only a limited number of studies have specifically examined adherence in patients with COPD therapy, and most research was conducted before the widespread availability of inhaled medications taken once or twice daily. In some original articles, many patient characteristics, such as the degree of bronchial obstruction or symptoms like dyspnea, are missing. However, it is well known that dyspnea, fear of dyspnea, and feelings of vulnerability contribute to better adherence to medication. Poor adherence to therapy, therefore, does not seem to make much sense from a clinical point of view, especially in these very symptomatic patients with COPD Gold stage B or D. Poor medication adherence in COPD has become a dogma that may well not correspond to reality, at least in patients with greater severity, and as such remains an open issue that merits further investigation.3

Another persistent dogma is the belief that once-daily medication is the best alternative for all COPD patients,4 because it is easier to use and improves compliance. As effort dyspnea is the main symptom of COPD, the most commonly recommended schedule for bronchodilator therapy administration is early morning. Many patients, however, experience an evening aggravation or at least a fear of a nocturnal aggravation of dyspnea. Patients use inhalers because they feel relief from their dyspnea. As therapy in COPD is to some extent driven by symptoms, a twice-daily bronchodilator regimen may be more suitable in certain patient groups, such as those with exacerbating phenotypes or asthma-COPD overlap syndrome (ACOS).

The introduction of inhaled corticosteroids (ICs) to COPD therapy has been widely debated in medical and scientific communities. Weaning from ICs in COPD, and 4 other important randomized trials that evaluated the effect of IC discontinuity (COPE, COSMIC, INSTEAD, and WISDOM), have also created considerable controversy.5 However, ICs in association bronchodilators have long been a mainstay of treatment for COPD. It was only the recent introduction of new long-acting bronchodilators, specifically developed for the treatment of COPD, and new fixed combinations of LABA-LAMA that led to the current debate in the medical community.6 There is now enough clinical evidence to challenge the widespread use of IC in COPD in patients who do not suffer from exacerbations and who have not shown any benefit with ICs.7

The science of medicine is characterized by its evidence-based approach and its revisibility. As a human activity, it is necessarily subject to dogmas and beliefs. Whether it was the medical representation of COPD as an inflammatory disease or the medical belief of a real benefit to the patient that led to the widespread use of ICs in COPD is still unclear. However, the medical community must wonder how real-life patients in real-life situations are represented in large randomized studies (often double-blind, placebo-controlled trials) supporting evidence-based medicine.