Clinical Question For patients wi...

Clinical Question

For patients with asthma, does the addition of a long-acting [beta.sub.2] agonist allow the dosage of maintenance inhaled corticosteroids to be reduc while maintaining asthma control?

Evidence-Based Answer

For adult patients who are taking a minimum maintenance dosage of inhaled corticosteroid for asthma, adding a long-acting [beta.sub.2] agonist permits reduction of the dosage of inhaled corticosteroid by means of 253 mcg beclomethasone equivalent by day without worsening the patient's symptoms. In patients taking higher dosages of corticosteroids, the import of adding a long-acting [beta.sub.2] agonist was flat more pronounced, with a mean reduction in their maintenance inhaled corticosteroid of 600 mcg beclomethasone equivalent for day. There is no evidence of improved symptoms with combination treatment, and it is not commended as initial treatment for asthma.

Practice Pointers

In adults and children whose asthma is not adequately controll with inhaled corticosteroids, adding a long-acting [beta.sub.2] agonist improves lung function and make lesss the risk of exacerbation. Adding a long-acting [beta.sub.2] agonist does not increase serious side weights or withdrawal rates when compared with inhaled steroids alone. (1) Long-acting [beta.sub.2] agonists alone have proven effective compared with placebo, on the contrary there are serious concerns about safety. A large studious mood comparing salmeterol (Serevent) with placebo was stopped prematurely because of an increase in the risk of death in the active treatment cluster (2-4)

Gibson and colleagues studied long-acting [beta.sub.2] agonists as corticosteroid-sparing agents to further refine their part in the treatment of asthma. They lay the foundation of 10 parallel randomized controlled trials involving adult patients who required daily inhaled corticosteroids. Trial quality was upright and the power of the studies was adequate. The trials compared inhaled corticosteroids with combination treatment with reduced-dosage inhaled corticosteroids and a long-acting [beta.sub.2] agonist. Patients were followed for three to 12 month The mean reduction in the dosage of inhaled corticosteroid was 60 percent

The researchers set up no significant differences between the arranges in exacerbations requiring oral steroids or in withdrawal from the reflection because of worsening airway inflammation. In the arrange that used combined treatment, forced expiratory convolution in one second improved compared with baseline (weighted mean difference 010; 95% confidence interval, 007 to 012) there was a small on the other hand significant improvement in morning peak expiratory issue and there were fewer days when short-acting [beta.sub.2] agonists were privationed These results suggest that the [beta.sub.2] agonists were not masking worsening airway inflammation.

Because adding a long-acting [beta.sub.2] agonist is effective in reducing the steroid dosage in patients maintaining disease have the direction of with long-term inhaled steroids, it is reasonable to question whether combined treatment should be the initial treatment in patients with mild to moderate airway obstruction. This question was addressed by way of Ni Chroinin and colleagues, (5) who construct that in a steroid-naive population with asthma, combined therapy does not significantly remodel the rate of exacerbations above inhaled corticosteroids alone. Combined thereapy may improve lung function and symptom-free days, on the contrary it does not reduce the use of short-acting [beta.sub.2] agonists. Overall, there is not sufficient evidence to praise initiating combined therapy for patients who have none had a trial of inhaled corticosteroids, particularly given the preciousness of two drugs compared with common (5)

Source: Gibson PG et al. Long-acting [beta.sub.2]-agonists as an inhaled corticosteroid-sparing agent for chronic asthma in adults and children. Cochrane Database Syst Rev 2005;(4): CD005076

REFERENCES

(1) Ni Chroinin M Greenstone IR, Danish A, Magdolinos H Masse V Zhang X et al. Long-acting [beta.sub.2]-agonists versus placebo in addition to inhaled corticosteroids in children and adults with chronic asthma. Cochrane Database Syst Rev 2005;(4):CD005535

(2) Walters EH Walters JA, Gibson MD Long-acting [beta.sub.2]-agonists for stable chronic asthma. Cochrane Database Syst Rev 2003;(3):CD001385

(3) Lemanske RF Jr Sorkness CA, Mauger EA, Lazarus SC Boushey HA, Fahy JV et al. Inhaled corticosteroid reduction and elimination in patients with persistent asthma receiving salmeterol: a randomized controll trial. JAMA 2001;285:2594-603

(4) Lurie P Wolfe SM Misleading data analyses in salmeterol (SMART) reflection [Letter]. Rickard KA. GlaxoSmith-Kline's rejoin Lancet 2005;366:1261-2.

(5) Ni Chroinin M Greenstone IR, Ducharme FM Addition of inhaled long-acting [beta.sub.2]-agonists to inhaled steroids as first line therapy for persistent asthma in steroid-naive adults. Cochrane Database Syst Rev 2004;(4):CD005307

The series coordinator for AFP is Clarissa Kripke, MD Department of Family and Community Medicine, University of California, San Francisco.

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