Dear Editor

Price and colleages conclude that adding formoterol confers a therapeutic advantage to inhaled steroid in patients with mild to moderate asthma. For the 6 month follow up in part 2 of the study, for the secondary outcome of mild asthma exacerbations,the frequency differed by 2.5 per patient per 6 months ,while for poorly controlled asthma days the difference was 4.2 days per patient per 6 months.

These differences while statistically significant are unlikely to be of real clinical relevance. Indeed during the same period, the difference in quality of life was neither significant nor clinically relevant. The main differences which were significant, were in bronchodilator sensitive outcomes such as peak flow and reliever use,which are to be expected when patients are taking a 24/7 bronchodilator. These data are little different from that in steroid naive patients in the OPTIMA trial over 12 months, where adding formoterol to low dose budesonide improved lung function but not exacerbations, while in the same trial for prior corticosteroid treated patients,adding formoterol conferred only a small but significant reduction in exacerbations.[1] Pointedly neither of these studies evaluated any inflammatory surrogates. We would therefore suggest that these trials indicate that most patients with mild to moderate asthma can be adequately controlled on low to medium doses of inhaled budesonide alone and that there is only a marginal advantage conferred by adding in formoterol. Morevoer combination inhalers are considerably more expensive than inhlaed steroid alone and their routine use is not warranted in primary care.

Reference

(1) O'Byrne PM, Barnes PJ, Rodriguez-Roisin R, et al. Low dose inhaled budesonide and formoterol in mild persistent asthma: the OPTIMA randomized trial. Am J Respir Crit Care Med 2001;164:1392-7.