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• Paucity of evidence guiding patients during deteriorating asthma control
  Graeme P Currie
  Published on: 16 July 2004

• Published on: 16 July 2004

  Paucity of evidence guiding patients during deteriorating asthma control

  • Graeme P Currie
  • Other Contributors:
    • Daniel KC Lee, Department of Respiratory Medicine, Ipswich Hospital, Ipswich IP4 5PD.

  Dear Editor,

  The paper by Fitzgerald et al [1] raises important questions as to what patients should be advised to do during periods of less well controlled asthma. In other words, the commonly advised practice of doubling the inhaled corticosteroid dose is not backed up by a wealth of evidence, in turn resulting in an embarassing paucity of clear guidance for patients.

  It has become apparent in the...

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  Dear Editor,

  The paper by Fitzgerald et al [1] raises important questions as to what patients should be advised to do during periods of less well controlled asthma. In other words, the commonly advised practice of doubling the inhaled corticosteroid dose is not backed up by a wealth of evidence, in turn resulting in an embarassing paucity of clear guidance for patients.

  It has become apparent in the management of chronic asthma, that additional 2nd line controller therapy is generally more advantageous than doubling the dose of inhaled corticosteroid. [2] In the treatment and prevention of asthma exacerbations, a similar pharmacotherapeutic rationale may also become the norm and be incorporated into individualised asthma action plans. In other words, adding further 2nd line therapy for a short period of time during deteriorating asthma control - while maintaining the same inhaled corticosteroid dose - may be appropriate.

  For example, the hybrid actions of leukotriene antagonism would attenuate airway hyperresponsiveness and further dilate the airways, while add on long acting ß2-agonist would maximally bronchodilate the airways with the provision of an “airway stabilising effect”.[3] Indeed, Aalbers et al 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. Perhaps in asthmatics already using an inhaled corticosteroid plus long acting ß2-agonist, the addition of montelukast may be worthwhile, as “triple therapy” has been shown to confer further benefit in terms of surrogate inflammatory biomarkers and attenuating airway hyperresponsiveness.[5]

  In conclusion, studies evaluating the effects of “short bursts” of leukotriene receptor antagonists or add-on long acting ß2-agonists compared to doubling the inhaled corticosteroid dose during deteriorating asthma control are urgently required.

  Graeme P Currie

  Daniel K C Lee †

  Department of Respiratory Medicine, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, Scotland, United Kingdom

  † Department of Respiratory Medicine, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, Suffolk, England, United Kingdom

  References

  1. FitzGerald JM, Becker A, Sears MR, et al. Doubling the dose of budesonide versus maintenance treatment in asthma exacerbations. Thorax 2004;59:550–6

  2. British Guideline on the Management of Asthma. Thorax 2003; 58 (Suppl 1):1-83.

  3. 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.

  4. 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.

  5. Currie GP, Lee DKC, Haggart K, et al. Effects of montelukast on surrogate inflammatory markers in corticosteroid treated patients with asthma. Am J Respir Crit Care Med 2003; 167:1232-8.

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  Conflict of Interest:
  None declared.

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