Rescue Inhalers With Bronchodilators and ICS?
Rescue Inhalers With Bronchodilators and ICS?
Papi A, Canonica GW, Maestrelli P, et al
N Engl J Med. 2007;356:2040-2052
Current national treatment guidelines call for the use of regular, low-dose inhaled corticosteroids for the treatment of mild persistent asthma. Unfortunately, regular compliance with such programs remains sporadic. Current guidelines also recommend the use of short-acting bronchodilators as rescue therapy for asthma symptoms, even though there is both bronchoconstriction and inflammation present in the airways of asthmatics. The effectiveness of inhaled corticosteroids for asthma is unquestioned; they have been shown to improve asthma control, improve quality of life, and reduce asthma morbidity and mortality. The problem is that many patients take them only sporadically. Often, they do not take their asthma medications until they start to notice increasing symptoms of shortness of breath, ie, "waiting until it rains to fix the roof." These authors decided to formally study this approach, namely using combination albuterol and beclomethasone in a single inhaler when asthma symptoms increase. There is mixed evidence regarding the effectiveness this approach, namely using inhaled corticosteroids to assist in the treatment of acute asthma symptoms.
These investigators studied whether symptom-driven use of a combination inhaler containing beclomethasone and albuterol would be as effective as regular use of inhaled beclomethasone and superior to inhaled albuterol alone used on an as-needed basis. This was a double-blind, double-dummy, randomized, parallel-group trial conducted over 6 months. Following a 4-week run-in period, patients were randomized into 1 of 4 treatment arms: combined albuterol and beclomethasone taken as needed in a single inhaler (as-needed combination therapy); as-needed albuterol therapy; regular beclomethasone twice daily with as-needed albuterol; or regular beclomethasone and albuterol taken twice daily plus as-needed albuterol. Morning peak expiratory flow rates were the primary outcome.
They studied 455 patients with mild persistent asthma, and found that morning peak expiratory flow rates were higher, and the number of asthma exacerbations was lower in the as-needed combination therapy group compared with the group receiving as-needed albuterol, but similar to those receiving regular beclomethasone or regular combination therapy with albuterol and beclomethasone. Those in the study arm taking the combination inhaler ended up taking significantly less inhaled corticosteroid than those taking regular beclomethasone or regular combination therapy.
The authors concluded that symptom-driven use of a combination of inhaled beclomethasone and albuterol is as effective as regular use of inhaled beclomethasone or combination inhaled beclomethasone and albuterol and is associated with a smaller cumulative dose of inhaled corticosteroid over a 6-month period.
Viewpoint
As a physician, ensuring compliance with a medical treatment program is one of the challenges of caring for patients with a chronic disease in which there may be long periods of time in which they may not experience symptoms. Mild persistent asthma is such a condition. This is another study suggesting that we may be able to use as-needed inhaled corticosteroids to improve asthma control. There are conflicting data, however, on whether regular inhaled corticosteroids may alter the natural history of asthma. This study was not long enough in duration to address whether intermittent use of inhaled corticosteroid may affect the longer-term course of the disease.
Abstract
Papi A, Canonica GW, Maestrelli P, et al
N Engl J Med. 2007;356:2040-2052
Current national treatment guidelines call for the use of regular, low-dose inhaled corticosteroids for the treatment of mild persistent asthma. Unfortunately, regular compliance with such programs remains sporadic. Current guidelines also recommend the use of short-acting bronchodilators as rescue therapy for asthma symptoms, even though there is both bronchoconstriction and inflammation present in the airways of asthmatics. The effectiveness of inhaled corticosteroids for asthma is unquestioned; they have been shown to improve asthma control, improve quality of life, and reduce asthma morbidity and mortality. The problem is that many patients take them only sporadically. Often, they do not take their asthma medications until they start to notice increasing symptoms of shortness of breath, ie, "waiting until it rains to fix the roof." These authors decided to formally study this approach, namely using combination albuterol and beclomethasone in a single inhaler when asthma symptoms increase. There is mixed evidence regarding the effectiveness this approach, namely using inhaled corticosteroids to assist in the treatment of acute asthma symptoms.
These investigators studied whether symptom-driven use of a combination inhaler containing beclomethasone and albuterol would be as effective as regular use of inhaled beclomethasone and superior to inhaled albuterol alone used on an as-needed basis. This was a double-blind, double-dummy, randomized, parallel-group trial conducted over 6 months. Following a 4-week run-in period, patients were randomized into 1 of 4 treatment arms: combined albuterol and beclomethasone taken as needed in a single inhaler (as-needed combination therapy); as-needed albuterol therapy; regular beclomethasone twice daily with as-needed albuterol; or regular beclomethasone and albuterol taken twice daily plus as-needed albuterol. Morning peak expiratory flow rates were the primary outcome.
They studied 455 patients with mild persistent asthma, and found that morning peak expiratory flow rates were higher, and the number of asthma exacerbations was lower in the as-needed combination therapy group compared with the group receiving as-needed albuterol, but similar to those receiving regular beclomethasone or regular combination therapy with albuterol and beclomethasone. Those in the study arm taking the combination inhaler ended up taking significantly less inhaled corticosteroid than those taking regular beclomethasone or regular combination therapy.
The authors concluded that symptom-driven use of a combination of inhaled beclomethasone and albuterol is as effective as regular use of inhaled beclomethasone or combination inhaled beclomethasone and albuterol and is associated with a smaller cumulative dose of inhaled corticosteroid over a 6-month period.
Viewpoint
As a physician, ensuring compliance with a medical treatment program is one of the challenges of caring for patients with a chronic disease in which there may be long periods of time in which they may not experience symptoms. Mild persistent asthma is such a condition. This is another study suggesting that we may be able to use as-needed inhaled corticosteroids to improve asthma control. There are conflicting data, however, on whether regular inhaled corticosteroids may alter the natural history of asthma. This study was not long enough in duration to address whether intermittent use of inhaled corticosteroid may affect the longer-term course of the disease.
Abstract
