We agree with Mr. Vermeulen that prescribing decisions must be sensitive to cost issues. It is important to emphasize, however, that concern about economic factors should not deter clinical investigations designed to advance the understanding of pathogenic mechanisms and development of more effective therapy. Our study was conducted several years before (and submitted for publication several months before) intranasal ipratropium was approved by the Food and Drug Administration. Our results were not intended to endorse use of this product but rather to indicate its degree of clinical effectiveness and tolerability in adults with uncomplicated colds. Clearly, many health problems for which patients seek relief of symptoms are self-limiting (for example, analgesics for headache and minor pain and antitussives for cough). In addition, as recently documented by Mainous and colleagues [1], most patients treated in ambulatory settings for apparently uncomplicated colds receive a prescription for an antibiotic agent. Such inappropriate use of antibiotic agents raises several concerns, including the development of drug-resistant bacteria.

Mr. Vermeulen is incorrect in stating that common colds have "almost no morbidity." Increasing evidence indicates that rhinoviral infections (the most frequent cause of colds) are associated with otitis media, sinusitis, exacerbations of asthma and chronic lung disease, and, in infants, serious lower respiratory tract disease [2-5]-conditions that have important medical and economic consequences. Whether antiviral or symptom-relieving interventions can be of benefit remains to be determined. Treatments that reduce the dissemination of infectious secretions into the environment (for example, by decreasing virus replication or by decreasing the severity of rhinorrhea or other symptoms) may be associated with reduced risk for secondary infections in close contacts. Our trial was not designed to address these questions but did provide evidence that relief of rhinorrhea contributes to an overall patient benefit. We hope that the information provided by our study will help patients and physicians make appropriate decisions about the use of intranasal ipratropium in the context of its current prescriptive cost.