Introduction and Objectives 10% of patients with asthma have disease that is refractory to conventional therapy. Two important factors in this group of patients are non-adherence to prescribed treatment and steroid insensitive airway inflammation. We report on our experience using intramuscular (IM) triamcinolone to evaluate such patients.
Methods We identified 28 patients who were on BTS step 5 treatment for asthma and at risk of fatal or near fatal events, who were given IM triamcinolone in the Glenfield difficult asthma clinic. The primary reason for administration of IM triamcinolone was to evaluate whether these patients had evidence of steroid insensitivity or were potentially non adherent. Adherence was assessed objectively prior to commencing triamcinolone. Juniper asthma control questionnaire (JACQ), fraction of exhaled nitric oxide (FeNO), blood eosinophils, sputum eosinophils, FEV1 (pre bronchodilator) were measured at baseline and whilst on triamcinolone.
Results Triamcinolone was administered monthly at a dose of 40–80 mg for a median (range) course of 4 (1–19) months. Patient demographics were: 75% (21) female, mean age 40 y, mean BMI 29.1, median dose of ICS (BDP equivalent) 2000 mcg, median dose of maintenance prednisolone 20 mg, 29% (8) had previously been ventilated. Adherence was objectively assessed in 93% (26) with non-adherence demonstrated in 77% (20), either by prescription refill check or drug assays. Significant improvements were seen whilst on triamcinolone in the mean JACQ score from 3.66 to 2.52 (p=0.0003), geometric mean FeNO from 52.3 ppb to 17.8 ppb (p=0.0034), mean blood eosinophils from 0.59×109/l to 0.22×109/l (p=0.0032), geometric mean sputum eosinophil count from 12.93% to 1.24% (p<0.0001) and in pre bronchodilator FEV1 from 54% to 67% predicted (p=0.0003). Of 28 patients receiving IM triamcinolone, 68% (19) showed significant improvement in 2 or more disease markers, 7% (2) showed improvement in 1 disease marker, 18% (5) had an equivocal response and 7% (2) demonstrated no response to parenteral steroid. No significant adverse events were reported.
Conclusions This study shows that IM triamcinolone is a useful tool that may identify non-adherence in difficult-to-control asthmatic patients prescribed maintenance oral corticosteroids. Absolute steroid resistance is uncommon in this group.