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Stepping down the dose of inhaled corticosteroids in asthma management
Stepping down the dose of inhaled corticosteroids in asthma management
dence in each group). The total oral steroid dose used over the 1-year study period was not significantly different in the 2 groups. Quality of life, assessed in a study questionnaire, was also not significantly different in the 2 groups. Three serious asthma-related adverse events occurred, only one of which happened after reduction of the ICS dose. The authors concluded that the dose of ICS can often be reduced significantly in stable asthma without adversely affecting the course of the disease. However, they admitted that a possible confounding factor was that 37% of the patients in the step-down group (and 30% in the control group) were receiving treatment with inhaled long-acting β agonists at the same time. A previous study has shown that addition of long-acting β agonists treatment allows a reduction of approximately 50% in the daily dose of ICS required for control of moderate persistent asthma; however, total elimination of ICS therapy in such patients results in a significant deterioration in asthma control (JAMA 2001;285:2594-603). One would have liked to see a lower frequency of acute asthma flares in both treatment groups and more detailed pulmonary function studies in this current study. Nevertheless, these findings support the conclusion that the beneficial effects of ICS in chronic, stable asthma plateau at doses above 800 to 1000 µg/day of beclomethasone or equivalent doses of other ICSs. Thus, a number of asthmatic patients might be receiving ICS doses higher than are required for them to receive the full beneficial effect of this therapeutic approach. (Hawkins et al. BMJ 2003;326:1115-7.)
Although the primary role of treatment with inhaled corticosteroids (ICSs) in persistent asthma is well accepted, questions have been raised as to whether some asthmatic individuals receive higher doses of ICSs than are needed for asthma control. This question was addressed in a randomized, double-blind study comparing the effect of reducing the dose of ICS by 50% versus unaltered ICS dosage in 259 adults with chronic, stable asthma who were being treated in a number of primary care practices in the United Kingdom with at least 1000 µg/day of inhaled beclomethasone (or an equivalent dose of another ICS). After a follow-up period of 1 year, the patients in the ICS dose step-down group had received a significantly lower dose of ICS (mean, 348 µg/day of beclomethasone or the equivalent) than those in the unaltered ICS dose group (P < .001); nevertheless, there was no significant difference between the 2 groups in the frequency of acute asthma exacerbations or unscheduled physician visits requiring treatment with oral steroids (approximately 30% inci-
Page 1256
December 2003
J ALLERGY CLIN IMMUNOL
dence in each group). The total oral steroid dose used over the 1-year study period was not significantly different in the 2 groups. Quality of life, assessed in a study questionnaire, was also not significantly different in the 2 groups. Three serious asthma-related adverse events occurred, only one of which happened after reduction of the ICS dose. The authors concluded that the dose of ICS can often be reduced significantly in stable asthma without adversely affecting the course of the disease. However, they admitted that a possible confounding factor was that 37% of the patients in the step-down group (and 30% in the control group) were receiving treatment with inhaled long-acting β agonists at the same time. A previous study has shown that addition of long-acting β agonists treatment allows a reduction of approximately 50% in the daily dose of ICS required for control of moderate persistent asthma; however, total elimination of ICS therapy in such patients results in a significant deterioration in asthma control (JAMA 2001;285:2594-603). One would have liked to see a lower frequency of acute asthma flares in both treatment groups and more detailed pulmonary function studies in this current study. Nevertheless, these findings support the conclusion that the beneficial effects of ICS in chronic, stable asthma plateau at doses above 800 to 1000 µg/day of beclomethasone or equivalent doses of other ICSs. Thus, a number of asthmatic patients might be receiving ICS doses higher than are required for them to receive the full beneficial effect of this therapeutic approach. (Hawkins et al. BMJ 2003;326:1115-7.)
Although the primary role of treatment with inhaled corticosteroids (ICSs) in persistent asthma is well accepted, questions have been raised as to whether some asthmatic individuals receive higher doses of ICSs than are needed for asthma control. This question was addressed in a randomized, double-blind study comparing the effect of reducing the dose of ICS by 50% versus unaltered ICS dosage in 259 adults with chronic, stable asthma who were being treated in a number of primary care practices in the United Kingdom with at least 1000 µg/day of inhaled beclomethasone (or an equivalent dose of another ICS). After a follow-up period of 1 year, the patients in the ICS dose step-down group had received a significantly lower dose of ICS (mean, 348 µg/day of beclomethasone or the equivalent) than those in the unaltered ICS dose group (P < .001); nevertheless, there was no significant difference between the 2 groups in the frequency of acute asthma exacerbations or unscheduled physician visits requiring treatment with oral steroids (approximately 30% inci-
Page 1256
December 2003
J ALLERGY CLIN IMMUNOL