No breath of relief for asthma patients

4 minute read

High-dose inhaled corticosteroids doesn't help poorly controlled asthma, yet can lead to higher rates of exacerbations and antibiotic scripts.

Giving patients a high dose of inhaled corticosteroids does not appear to improve outcomes for patients with poorly controlled asthma, according to a recent study.

And the new research, published in the Journal of Allergy and Clinical Immunology, found a higher dose could actually increase the risk of health complications such as asthma exacerbations.

To determine whether upping the dose of inhaled corticosteroids would confer any benefit to patients with poorly controlled asthma and/or high blood eosinophil count, the researchers conducted a historic cohort study of longitudinal medical records from two large UK primary care databases.

The study included around 74,500 patients aged 13 years and over, of which about 51,700 remained on medium-dose inhaled corticosteroids for the duration of the study. A further 6800 patients moved from medium-dose to high-dose inhaled corticosteroids, 12,600 from low-dose to medium-dose and 3200 from low-dose to high-dose.

The researchers found no evidence that increasing to a high dose of inhaled corticosteroids reduced moderate or severe exacerbations.

People who continued on a medium dose waited, on average, 2.7 years for their first exacerbation. But those who increased from medium-dose to high-dose had an exacerbation after only 2.0 years and those who jumped from low-dose to high-dose waited only 2.3 years.

Over the one-year follow up period, patients who increased their dosage from medium to high were 17% more likely to have an exacerbation, compared to those who stuck with their original dose. Similarly, those who stepped up their dose from low to high were 10% more likely to have an exacerbation compared to those who stepped up from low to medium.

An increase to high-dose inhaled corticosteroids was also associated with higher rates of antibiotic prescriptions for lower respiratory tract infections.

“We found no evidence that a step-up to high-dose corticosteroids is effective in preventing future asthma exacerbations and support the current GINA steps of management and the introduction of alternative treatment strategies for those who remain uncontrolled, including biologic therapies,” the authors wrote.

“Our results do not exclude the need to increase inhaled corticosteroids dose, but rather encourage physicians to consider if such an increase is necessary and beneficial and serve as a reminder to follow-up patients stepped up to higher inhaled corticosteroids dose in order to gauge response.”

According to National Asthma Council Australia Director and respiratory physician Professor Peter Wark, the findings call into question the current approach of stepping up to high-dose inhaled corticosteroids, especially based on symptoms or exacerbations alone.

“If patients remain poorly controlled, despite medium-dose inhaled corticosteroids/long-acting beta-agonists, then automatically stepping up to high-dose inhaled corticosteroids for a long time may not be the best strategy,” he said.

“Those who do not have high blood eosinophils may benefit from long-acting muscarinic antagonists. In those with high blood eosinophils, high-dose inhaled corticosteroids may help, but they should consider whether they should be referred to a specialist and/or use a biologic agent.”

He highlighted step four of the National Asthma Council Australia guidelines as an important point at which GPs should look more closely, identify the nature of the problem and the patient’s phenotype (high type 2 inflammation, high blood eosinophils or exhaled nitric oxide) and consider a biologic.

“The National Asthma Council guidelines now look at phenotypes in step five of treatment,” he said.

“These results suggest it needs to be considered earlier.”

The authors said that their findings support previous research that concluded “80-90% of the maximum obtainable benefit of ICS is seen with a ‘low’ dose with minimal additional clinical benefit from ‘high’ dose ICS in patients with moderate to severe asthma”.

The GINA steps for asthma management and prevention were devised by the Global Initiative for Asthma with the aim of raising awareness and improving asthma care. They comprise essential components and goals including patient education, identifying and minimising triggers, monitoring for symptom changes and pharmacologic therapy.

Journal of Allergy and Clinical Immunology2022, online 8 November

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