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The paper by Fitzgerald et al  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
It has become apparent in the...
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.  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”. 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
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
1. FitzGerald JM, Becker A, Sears MR, et al. Doubling the dose of
budesonide versus maintenance treatment in asthma exacerbations. Thorax
2. British Guideline on the Management of Asthma. Thorax 2003; 58
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.