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Re: What should patients do when asthma becomes less well controlled?

Dear Editor

The evidenced based-review by Gibson and Powell [1] highlights the benefit of written action plans when incorporated into the care of asthmatic patients. It is important to note that in most of their randomised controlled trials, patients were instructed to at least double the inhaled corticosteroid dose during deteriorating asthma control. A study in the Lancet has however provided little evidence that doubling the inhaled corticosteroid dose per se confers direct benefit in terms of reducing requirement of prednisolone.[2]

Recent data [3] demonstrated that the use of budesonide and eformoterol in combination, with dose adjustment according to patients symptoms, conferred benefit in terms of exacerbations, lung function and reliever use. Indeed, this approach may well be best suited to asthmatics with impaired lung function where the long acting ß2-agonist moiety would maximally dilate the airways along with a concomitant “airway stabilising effect” on exposure to a bronchoconstrictor stimulus.[4] Such patients are likely to be on top of the dose-response curve for effects of inhaled corticosteroids upon lung function,[5] suggesting that additional bronchodilator therapy might be of greater value than doubling the corticosteroid dose in less well controlled asthma.

Further studies are required to establish whether combined corticosteroid/ long acting ß2-agonist inhalers - especially in patients with impaired lung function - confer superiority compared to doubling the inhaled corticosteroid dose in individualised asthma action plans.

References

1. Gibson PG, Powell H. Written action plans for asthma: an evidenced -based review of the key components. Thorax 2004; 59: 94-9.

2. Harrison TW, Oborne J, Newton S, Tattersfield AE. Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial. Lancet 2004; 363: 271-5.

3. Aalbers R, Backer V, Kava TTK, et al. Adjustable maintenance dosing with budesonide/formoterol compared with fixed-dose salmeterol/fluticasone in moderate to severe asthma. Curr Med Research and Opinion 2004; 20: 225-40.

4. Currie GP, Jackson CM, Ogston SA, Lipworth BJ. Airway-stabilising effect of long-acting ß2-agonists as add-on therapy to inhaled corticosteroids. QJM 2003; 96: 435-40.