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There is increasing evidence that steroids should be used as early as possible in all patients with asthma, not only to control symptoms1-3 but also to prevent structural damage to the lungs from the effects of chronic inflammation.4 If started early enough there is also a chance of switching off the immune response. This means using steroids as soon as the diagnosis of asthma has been confirmed. Bronchodilators would then be kept in reserve for rescue treatment if necessary.
The present BTS guidelines advise starting treatment with β agonists for “mild” asthma (Step 1) and steroids are only given if there is poor control or too much β agonist is being used (Step 2). Thus, β agonists are widely regarded as the treatment for asthma with steroids as an optional extra. This delays the use of steroids, depriving patients of better symptom control3 and allowing progressive deterioration in lung function due to irreversible airway obstruction.4 5 It also enables patients to become dependent on β agonists due to rebound bronchial hyperresponsiveness—a difficult habit to break even when steroids are introduced.6
While many clinicians agree in theory with this new approach, they are reluctant to deviate from the BTS guidelines in practice. If Step 1 was removed it would enable us to start at Step 2, using steroids as first choice for all newly diagnosed asthmatic patients.
authors’ reply The issue that Dr Strube raises, namely whether or not inhaled corticosteroids should be used as first line treatment for all newly diagnosed asthmatic patients, is certainly a question which needs to be addressed. However, it cannot be looked at in isolation from other issues such as the role in asthma management of other newer “anti-inflammatory” medications such as the anti-leukotrienes.
Published guidelines can only reflect the state of knowledge and evidence available at the time they were produced, and should not deter individual clinicians from adopting newer approaches to management where appropriate. By definition, guidelines provide guidance and are not intended to be proscriptive. Dr Strube’s suggestion undoubtedly needs to be taken into account and all the relevant evidence carefully evaluated for the next version of the Asthma Guidelines.
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