The management of asthma consists of the regular use of anti-inflammatory medications and an action plan for worsening of symptoms or an asthma exacerbation. Guidelines for the treatment of asthma have recommended doubling the dose of maintenance inhaled corticosteroids for deteriorations in asthma control that are not responding to β agonist rescue treatment in the usual manner.^1,2 Although this approach has been advocated, evidence to support its effectiveness has been largely wanting.

In this issue of Thorax FitzGerald and colleagues³ and members of the Canadian Asthma Exacerbation Study Group evaluated this approach. They identified 290 patients with well characterised asthma, all of whom had a history of at least one previous asthma exacerbation—defined as an increase in symptoms and the need for a change in medication not more than 12 months and not less than 1 month before the start of the run in period. During the run in period all subjects were maintained on their usual dose of inhaled corticosteroids. Subjects were then either assigned to maintenance treatment and received their usual dose of budesonide (100, 200, or 400 μg twice daily) plus a placebo inhaler to be used twice a day with an exacerbation, or were on the same doses of inhaled corticosteroid plus an inhaler containing active inhaled corticosteroid which therefore doubled their maintenance dose of inhaled corticosteroids during the exacerbation. …